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SUEGICAL ASPECTS 
OF DIGESTIVE DISORDERS 



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SURGICAL ASPECTS 



OF 



DIGESTIVE DISORDERS 



BY 



JAMES G. MUMFORD, M.D. 

VISITING SURGEON TO THE MASSACHUSETTS GENERAL HOSPITAL 

AND INSTRUCTOR IN SURGERY IN THE HARVARD 

MEDICAL SCHOOL 



IN ASSOCIATION WITH 



ARTHUR K. STONE, M.D. 

PHYSICIAN TO OUT-PATIENTS, MASSACHUSETTS GENERAL HOSPITAL 

AND ASSISTANT IN THE THEORY AND PRACTICE OF PHYSIC 

IN THE HARVARD MEDICAL SCHOOL 



SECOND EDITION 



Nefo gork 
THE MACMILLAN COMPANY 

LONDON: MACMILLAN & CO., Ltd. 

1907 

All rights reserved 



' ^ 



<tf 



LIBRARY ol CONGRESS 
OneCop* Received 

JUL 26 !90iT 

leM Entry 
Q XXc. No. 




Copyright, 1905, 1907, 
By THE MACMILLAN COMPANY. 



Set up and electrotyped. Published September, 1905. New edition 
July, 1907. 



NortoooU IJHregg 
J. S. Cushing Co. — Berwick & Smith Co. 

Norwood, Mass., U.S.A. 



TO 
JOHN COLLINS WARREN 

Surgeon Scholar Teacher 

WHOSE UNTIRING ZEAL FOR THE ADVANCEMENT OP 

MEDICINE 

WILL BE A LASTING INSPIRATION TO HIS 

PUPILS 



NOTE TO THE SECOND EDITION 

In the eighteen months which have elapsed since the 
first edition of this book appeared, a great deal of 
important surgical work has been done on the digestive 
organs ; but mostly it is work which confirms previous 
conviction. We believe that the argument of this 
book holds, and we offer the volume again without 
further apology. 



AEGUMENT 

The purpose of this volume is an estimate of what surgery 
may accomplish in diseases of the abdominal digestive organs ; 
we do not choose to consider here that part of the digestive 
apparatus connected with the buccal cavity, the fauces, the 
pharynx, and the oesophagus. In the great flood of more 
or less controversial writing and talking on the subject of 
our theme, few definite conclusions for the benefit of the 
general practitioner have yet been reached. Probably it is 
still too early for certainty, but by associating together a 
surgeon and an internist in the writing of this book, by 
examining our ascertained facts with an approach from dif- 
ferent, but not opposing, points of view, we hope to have 
arrived at certain broad and justifiable conclusions so far as 
present knowledge of the subject permits. 

The reader may be disappointed, perhaps, in the undog- 
matic character of our results ; we cannot say of disease of 
the bile passages and of gastric ulcer what has come to be 
said of appendicitis, that they are purely surgical diseases, 
but we believe we can show that in many instances they are 
so, and we insist that in all prolonged or severe disorders of 
such nature the views of a properly qualified surgeon should 
be sought. In other words, such diseases have passed out 
of the hands of the internist acting alone. He must share 
with the surgeon the responsibility, and share it early. 

A clear-headed surgeon has said, " If you have a patient 
who has suffered for two years from a chronic dyspepsia, 
unrelieved by internal treatment, you may fairly say that 
his case is probably a surgical one, and that relief may be 



viii ARGUMENT 

found from an operation upon one of five organs, — the 
stomach, the pancreas, the bile passages, the kidney, or the 
appendix." 

That is doubtless too broad a generalization, but it is 
worth bearing in mind. 

For some years we who write this have been in the habit 
of impressing upon our students the fact that the duodenum 
is the central chamber of the digestive apparatus (Fig. 1). 
Borelli taught something of this sort nearly three hundred 
years ago, and that ancient Italian master had a keen appre- 
ciation of physiological conditions. 

If we look broadly at the anatomical arrangement of the 
parts, we see that he was right. Into the duodenum the 
stomach empties its contents. Bile and the pancreatic juice 
flow into it, the right kidney is near it, and it is continued 
in the intestine, which lower down finds itself encumbered 
with the appendix vermiformis. 

All of these organs, including the duodenum itself, are 
subject to disease ; and with it all of these organs, excepting 
the appendix, are closely associated. The disease of one 
organ may involve the disease of others, — indeed, such asso- 
ciated diseases are commonly found, that of the appendix 
included ; so that a broad and philosophic view of digestive 
disturbances must take account of all these organs as a com- 
plex. It is a compound of many diseased organs with which 
we have to do. In writing one should not deal with them 
separately, as has usually been done; indeed, the common 
method of the text-books — the treating of digestive dis- 
eases upon an individualized anatomical basis — we regard 
as ineffective for an appreciation of this involved question. 

Historically the development of knowledge of the physi- 
ology and anatomy of the digestive organs was slow. Not 
until modern times has such knowledge become fairly 
rounded; while the therapeutics of the diseases concerned 
was practically stationary for centuries. We shall present a 
short sketch of the development of these matters, an under- 



ARGUMENT i x 

standing of which is essential to a broad appreciation of 
the situation which is now developing in medical practice. 

We shall take up the consideration of the individual 
organs concerned and of their diseases, bearing in mind 
always the close anatomical relationship of such organs 
with each other and the frequent interdependence of their 
diseases the one upon the other. 

The stomach is the organ most closely connected with the 
duodenum, so that the stomach first shall engage our atten- 
tion. Destructive inflammatory processes are far more com- 
mon in it than used to be supposed. Such processes and 
their sequelae lead to an infinite variety of anatomical 
changes, and to trains of symptoms which are too often 
assigned to chemical alterations in the digestive fluids. 
Such chemical alterations, when they exist, are frequently 
secondary and of secondary importance. If normal func- 
tion and health are to be restored, the question of damaged 
mechanism first must be considered ; and how this restora- 
tion may be accomplished is the central thought in our 
theme. The inflammatory processes in the stomach often 
cause inflammatory and crippling changes in other organs, 
the process spreading by direct continuity, so that the 
picture continues to alter in kaleidoscopic fashion. 

That the stomach itself undergoes profound alterations, 
varying with the time of life and with sex, is another strik- 
ing fact. The acute ulcer of young women, often spon- 
taneously healing, presents quite another problem from the 
chronic, intractable ulcer of middle-aged men. The latter 
form of ulcer is the one especially to which surgery brings 
relief. The dilated weak stomach of the alcoholic may be 
reduced and relieved by the measures of the internist ; the 
chronically distended stomach resulting from the cicatrized 
stenosis of a pyloric ulcer can be cured by surgical measures 
only. You must constantly, in your practice, be bearing in 
mind the great frequency of stomach dilatations, cicatrices, 
and adhesions associated with disturbances of digestion. If 



x ARGUMENT 

you will examine carefully all your cases of "dyspepsia," 
you will be surprised to see how frequently the stomach 
tympany extends below the umbilicus, and you will do well 
in all such cases to remember that surgery may be your 
resort, not tardily and rarely, but promptly and frequently. 
Early operation on these stomachs is safe, easy, and effec- 
tive ; late operation may be dangerous, difficult, and futile. 

The same statement applies to disease of the bile passages. 
You will find gall-stones in the ducts, associated with gastric 
ulcer ; you will find the gall-bladder adherent to the duode- 
num ; you will find cholangitis ; you will find calculi in the 
gall-bladder when you least expect them ; and you will find 
plugging of the ampulla of Vater, with consequent pan- 
creatitis. These are, for the most part, late manifestations, 
which might have been avoided by early operation. 

The various conditions may be single and simple, or they 
may be complicated ; and though frequently you may with 
medicine remove the symptoms and enable the patient to 
resume his regular course of life, signs of the old trouble 
are apt to return again and again, until chronic invalidism 
is established or the patient finds relief through surgery and 
the unravelling of the deranged mechanism. 

The constant irritation of a low grade of appendicitis, 
causing directly an involvement of the associated organs, 
and numerous dyspeptic symptoms with consequent malnu- 
trition, adds to our problem another factor frequently unap- 
preciated. That is a subject on which we propose to say an 
urgent word. 

Added to all these organic disturbances, there is another 
and important complication only recently appreciated, but 
still continually disregarded, — ptoses, displacements of the 
various abdominal organs ; displacements involving one or 
many or all ; ptoses of the stomach, the kidneys, the liver, 
the intestines, and, not by any means least, of the pelvic 
viscera. 

The field of the gynecologist may seem far removed from 



ARGUMENT xi 

the stomach, but the displaced uterus may experience an 
uncomfortable association with its superimposed fellow, and 
digestive disturbances of far-reaching significance may find 
their cause in combined stomach and uterine ptoses. 

To the overdriven general practitioner, or the man who 
has never turned his attention especially to disorders of 
digestion, it may seem that such conditions as we have de- 
scribed are infrequent and are related but Jittle to his ordi- 
nary routine. It is for precisely such physicians that we 
wish to point a moral. Dyspeptic conditions are common 
enough in your experience, though you may have accus- 
tomed yourself to think of them as transient, trifling, and 
easily treated. 

The patient who complains of morning headache, of occa- 
sional eructations, of some palpitation, and of constipation 
may be the victim of gastric cicatrices and beginning pyloric 
stenosis. 

The man who tells you that he is troubled with distress 
several hours after taking food and with occasional stomach- 
ache may be suffering from gastrectasis or gall-stones. 

The child with a poor appetite, pallor, lassitude, and con- 
stipation alternating with diarrhoea may have a chronic 
appendicitis. 

The rather frail, neurasthenic young girl or the tired 
mother of many children, the sufferer from dysmenorrhea, 
or the elderly widow with heartburn may be affected with 
displacements of the stomach, the kidneys, and the uterus. 

These examples are suggestions merely, but if you observe 
closely you will find them very true, and repeated over and 
over again in your daily round. That hundreds of dys- 
peptic symptoms are transient and may easily be treated, no 
man shall deny, but we must not be blinded by so simple a 
faith. Probably one at least out of every dozen of such 
cases has some definite anatomical derangement, and for 
such your search must be unwearied. 

As illustrating what may be accomplished in diagnosis by 



Xll 



ARGUMENT 



the careful investigation of cases, we have added, in an 
Appendix, the able paper of our colleague, Dr. Henry F. 
Hewes. 

In a large sense the purpose of this book is a discussion 
of current problems, — problems more or less familiar to the 
surgeon, less so perhaps to the practitioner of general medi- 
cine. To both classes of men we address ourselves, how- 
ever, and ask their consideration of the following pages. 




Fig. 1. — Supplement ; showing occasional relation of vermiform appendix with 
right kidney ; colon cut away ; retro-csecal appendix. 



CONTENTS 

CHAPTER I 



PAGE 

Ancient Conceptions of the Digestive Organs ... 1 



CHAPTER II 
Methods 35 

CHAPTER HI 
The Stomach 57 

CHAPTER IV 

Dilatation of the Stomach, treated without Operation . 82 

CHAPTER V 
Ulcer of the Stomach and Duodenum 99 

CHAPTER VI 

Operative Treatment of Non-malignant Diseases of the 

Stomach 139 

CHAPTER VH 
Cancer of the Stomach 198 

CHAPTER Vm 
The Bile Passages 226 

CHAPTER IX 

Surgery of the Bile Passages 249 

xiii 



xiv CONTENTS 



CHAPTER X 

PAGE 

The Pancreas . 276 



CHAPTER XI 

Abdominal Ptosis 298 

CHAPTER XH 

The Appendix Vermiformis 320 

Appendix 351 

Index 391 



SUEGICAL ASPECTS 
OF DIGESTIVE DISORDERS 



CHAPTER I 
ANCIENT CONCEPTIONS OF THE DIGESTIVE ORGANS 

In glancing back over the history of therapeutics 
one expects to find that from the earliest times 
digestive disorders especially attracted the attention of 
medical practitioners ; for of digestive disorders we 
are wont to think that they begin with infancy and 
persist through life more universally than do all other 
physical affections. Yet the ancients had much less 
solicitude for such disorders than have we. So far 
as one may judge from the early writings these dis- 
orders were infrequent and little regarded until later 
times. The reasons for this disregard or apparent 
immunity are obvious enough. Among primitive peo- 
ples, leading a rough, open-air life, eating a simple 
diet, near to nature as the phrase now runs, dyspepsia 
was little known. This was as true doubtless of the 
ancients as of those North American Indians whose 
bodily virtues and wholesome life our own Rush 
described less than a hundred and fifty years ago. 1 

So a good natural hygiene was found in the early 
days, and as civilization advanced, a good hygiene 
continually was preached. Among the Egyptians, the 
Jews, the Persians, the Greeks, beauty and strength 
of body were held the greatest good, and where nature 
failed, art stepped in to remedy defects. The book 

1 Benjamin Rush, " Natural History of Medicine among the Indians 
of North America." 1774. 



2 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

of Leviticus gives us the keynote to the regulated 
lives of the Jews, whose practices did not differ 
greatly from those of their Egyptian associates. Their 
frequent ablutions, their abstinence, their dietary, their 
activity, and their scrupulous relations with women 
all tended to the upbuilding and preserving of clean 
and vigorous bodies. 

Among the Persians, too, when at their best, before 
they were enervated with success and debauchery, the 
sound body was most to be desired, and, if we can 
believe what is written of them, their capacity for 
working and fighting with undiminished vigor on 
scanty rations and little sleep was amazing. 

The Greeks of the Hippocratic era seem to have 
regarded permanent physical ills as not deserving 
the attention of serious philosophic minds. To such 
an extent did they carry this thought that, in the 
schools of the Asclepiadae, chronic diseases are merely 
referred to, some are not even named, and very few 
are described. For chronic affections were regarded 
as inconveniences not meriting the attention of physi- 
cians. 1 

The important business of those old practitioners 
was the care of their men wounded in battle. Trau- 
matic surgery came first, then the preservation of 
women in childbirth, and then the study and conduct 
of acute diseases. Of course there were cases of 
acute digestive disorders, but the treatment was not 
intricate. Dietetics were of most importance, then 
emetics were given to clear the stomach, and drastic 
cathartics completed the simple scheme. Vomiting 

1 P. V. Renouard, " History of Medicine." 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 3 

was a recognized prophylactic. Says an author of 
the Hippocratic school, "He who is in the habit of 
vomiting himself twice a month will find more ad- 
vantage in doing so on two successive days than once 
every two weeks." 1 

It was all very natural and uncomplicated — 
treatment by those ancient men. They knew little 
of anatomy, of physiology still less. Cleanliness was 
their god ; they washed and polished and oiled the 
body for its good, and when the mysterious internal 
machinery went wrong they washed and cleaned and 
polished that, so far as in them lay. 

Through all the dreary blank of the Middle Ages, 
such little rational medicine as existed looked back to 
Galen (131-201 a.d.) and contented itself with com- 
mentaries upon his writings. Now Galen's physiol- 
ogy, while sound in many respects, was fragmentary, 
though he advanced our knowledge of anatomy. With 
Plato and Aristotle he made the soul play an impor- 
tant part in the animal economy. The soul had three 
parts or faculties : one resided in the liver and was 
called the vegetative ; another in the heart, the irasci- 
ble ; and another in the brain, the rational. And 
this was his view of the nutrition of the body : the 
food taken up from the intestines is carried to the 
liver and there turned into blood, for in the liver 
dwells the vegetative soul ; and this newly created 
blood carries thence " natural spirits." Then this 
blood is borne by the vena cava to the right side of 
the heart, where some of it is sifted through the 
ventricular septum into the left side. When the 

1 Ibid., p. 97. 



4 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

heart contracts and expands, the blood from both sides 
is forced backward and forward like the flow of the 
tides, some of it going to the lungs whence it draws 
air back into the left side of the heart, where it be- 
comes laden with " vital spirits," and thence ebbs back 
and forth through the rest of the system. This vital- 
ized blood goes to the brain, among other places, and 
there it generates the "animal spirits," which spirits, 
becoming separated from the blood, are carried as pure 
spirits along the nerves. So these are the spirits which 
effect motion and carry on the various higher animal 
functions. The above is one illustration of Galen's 
physiology. It was more elaborate than that of Hip- 
pocrates, for he knew more of anatomy than did the 
Father of Medicine. He was somewhat more accurate, 
but of the functions of the digestive organs he guessed 
little, while his practice followed the ancient simple 
methods. As Hunt says, "his comments upon the 
writings of Archigenes upon the pulse, his doctrines of 
the temperaments (the sanguine, cold and warm ; the 
phlegmatic, moist and cold ; the choleric, dry and 
warm ; the melancholic, dry and cold) and his dogma 
of < contraries,' which gave origin to the < allopathy ' 
of those who love to think and talk dogma, did as 
much or more than anything else to pad what might 
be called medical scholasticism. Perhaps the worst to 
be said of him is that he assisted in preserving the 
health of Commodus ; and the best, that he maintains 
much the same relative position in medicine as that 
occupied by Marcus Aurelius in philosophy." 1 

Then through a thousand years we see little change in 
1 David Hunt, " Talks on the History of Medicine." Boston, 1898. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 5 

the treatment of digestive disorders. Medicine pro- 
gressed doubtless. At first great names appear upon 
the roll, — names which it is needless to recall. Cus- 
toms and manners changed in some degree ; wealth, 
luxury, and evil living increased. The lusts of the body 
replaced the claims of grace and beauty and strength. 
The physical man declined as civilization advanced and, 
for a long period in the degenerate Greek and later 
Roman days, the ills of the flesh became as complicated 
and as much objects of interest and solicitude as among 
us moderns. But no new aid was there. Something 
more of anatomy was learned, some further suspicion 
of the functions of the organs crept in ; some striking 
advance in the art of surgery was made, but through 
it all and in spite of all, authority, not observation, 
ruled ; the same old drugs were given, the same 
crude means were used, the same mysterious pains, 
and nauseas, and " heart-burns," and " fluxions," and 
agonies, and fatalities prevailed until far past the dawn 
of modern times. 

We must regard Andreas Vesalius as the first of the 
modern masters in medicine, for he began to teach us 
how to study the human body, and though the Fabrica 
Humcmi Corporis, which appeared in 1543, deals mainly 
with anatomical problems, and though his physiology 
is largely that of Galen, he saw the value of the vivi- 
section of animals, and in a striking chapter pointed 
out the advantages of that method of study. But it is 
as an anatomist that he deserves our gratitude, for he 
threw aside authority and showed that only through an 
accurate and thorough knowledge of the structure of the 
body can we hope to arrive at a knowledge of function. 



6 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

After Vesalius, it is to Borelli, Malpighi, Paracelsus, 
Van Helmont, and Harvey that we owe more than to 
others of the seventeenth century, — at least so far as 
knowledge of function is concerned, — and they gave 
us some little new light on the problems of digestion. 
Borelli (1608-1679) was primarily a mathematician and 
a physicist, and he regarded his studies on the living 
body as providing a field in which to apply new 
methods of physical research. 1 A very important 
division of his work dealt with muscular mechanism. 
He devoted great attention to this and similar problems, 
and in remarkably correct fashion showed how some 
of the most important functions of the body, such as 
the movements of the limbs, the action of the heart, 
and the contraction of the blood-vessels are purely 
mechanical and can be investigated by the ascertained 
laws of mechanics. From such conclusions, which are 
in the main correct, it is easy to see how he leaped 
readily to similar conclusions regarding digestive pro- 
cesses, and advanced opinions concerning their more 
complex phenomena, in which he attempted to show 
that in them, too, we are still dealing with purely 
mechanical conditions. Some of his experiments in 
this direction were extremely ingenious, and may well 
have convinced an observer to whom chemistry was 
unknown. He called attention to the fact " < that in 
birds, with few exceptions, the crushing, erosion, and 
trituration of food is effected by the muscular stomach 
itself, compressing one part of its horny lining against 
another. Thus with the help of small, hard, and sharp 
pebbles contained in it, which serve instead of teeth, 

1 Foster's " History of Physiology," p. 67. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 7 

the stomach, by pounding the food swallowed and 
rubbing its inner surfaces on it this way and that, like 
millstones, crushes the parts of the food until they are 
converted into a very fine powder. ... I introduced 
by the mouth into the stomach of turkeys, glass glob- 
ules, or empty vesicles, and leaden cubes, similarly 
hollowed out, pyramids of wood, and many other things, 
and the next day I found the leaden masses crushed 
and eroded, the glass pulverized, and the remaining 
ingesta in the same condition.' " 1 

In spite of the apparent earnestness of such writing, 
it is a fact that up to, and even until after, this time, 
the physiology of digestion occupied men but little. 
As Foster says : " If you take up a text-book of modern 
physiology, you will find page after page occupied with 
chemical matters. In some text-books digestion and its 
consequences take up so large a space as to suggest to 
the reader that the stomach is the larger part of man. 
It is not so with the writings of Vesalius, . . . the 
whole of digestion and nutrition is dismissed in almost 
a single sentence." 

The microscope was lacking to Vesalius and Borelli, 
for the microscope was invented about 1590. After 
the middle of the seventeenth century Marcello Mal- 
pighi (1628-1694) began turning it to histological uses, 
which in his own lifetime, through himself and some 
few others, advanced enormously our conception of the 
intricate nature of the digestive processes. It would 
be a pleasant task to tell the life history of this accom- 
plished man. To most of us it is a name suggesting 
merely the minute anatomy of the kidney, but Malpighi 

1 Ibid., p. 165. 



8 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

was a laborer in many fields, all of which were left 
more fertile for his toil. Botanist, embryologist, natu- 
ralist, pathologist, biologist ; he was all of these, but 
it is especially as histologist that he attracts us. 

As a histologist, Malpighi explored many organs 
besides those concerned strictly with digestion. He 
was the first properly to describe the structure and 
function of the lungs ; in some fashion he recognized 
the arrangement of the fibres which connect the sur- 
face of the brain with the cord, he carrying his micro- 
scopical studies into other regions ; he explained the 
arrangement of the layers of the skin, and described the 
rete mucosum, sometimes known to us as the Malpighian 
layer ; more important still, he ascertained the presence 
of those disks which we recognize as red corpuscles in 
the blood stream, and by his discovery of the capillaries, 
completed the circle which had been left partly finished 
by Harvey. 

It is Malpighi's work on the glands, and especially 
the liver, that concerns us here ; very important work 
in the study of function, it was supplemented by the 
anatomical discoveries of other men, his contemporaries 
and immediate predecessors. In 1642 John George 
Wirsung, professor of anatomy at Padua, had discov- 
ered and demonstrated the duct of the pancreas, which 
is known by his name. In 1652 Thomas Wharton of 
London discovered the duct of the submaxillary gland, 
and in 1661 Nicolas Stenson investigated and described 
the duct of the parotid gland. So these three glands, 
salient in the bearing they have upon our subject, came 
to be regarded no longer as isolated structures, though 
their function was still undetermined by Wirsung, 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 9 

Wharton, and Stenson, whose observations halted with 
their demonstrations of the gross anatomy. In 1662 
Laurentio Bellini, a youthful pupil of Borelli, saw the 
kidney tubules, while eight years earlier the English- 
man, Francis Glisson, laboriously and elaborately had 
demonstrated that intricate liver capsule which bears 
his name. 

All these observations and ascertained facts were 
essential for the future work of Malpighi. It was in 
1666 then that he published his important book on the 
viscera, and he dealt with four organs, the brain, spleen, 
kidneys, and liver. Of the first three organs it suffices 
to say that with the exception of the brain, they were 
described in a fashion so admirable and final that for 
nearly a hundred and fifty years little more of impor- 
tance was added to knowledge concerning them. Of the 
liver, however, and Malpighi's conception of its relation 
to digestive processes it is interesting to say some word. 
In the first place, he showed, what was not before ap- 
preciated, that the liver is a conglomerate secreting 
gland in structure, and that its elements are arranged in 
small clusters which he named acini. As Foster says, 
that was the end of the mystery of the liver. It 
secreted bile, just as other glands secreted their peculiar 
products, and the bile took its origin from the liver and 
not from the gall bladder, as was being erroneously 
asserted by some. The previous work of Glisson was 
an important aid to Malpighi in making his point, and 
he pays his respects to that eminent anatomist, more 
than once, in the course of his argument. 

Nearly two hundred years before Malpighi there 
lived near Erfurt a Benedictine monk, Basil Valentine, 



10 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

known widely thereafter as the first among the Chym- 
ists} He is to be noted because he seems to have 
been the earliest to maintain the proposition that diges- 
tion is due to an acid-dissolving menstruum, and not to 
any mechanical action of the organs concerned. But 
more especially is he interesting to us because he influ- 
enced greatly the views of his famous successor Von 
Hohenheim, commonly known as Paracelsus. That 
last remarkable man precedes Malpighi by more than a 
hundred years ; indeed, he was somewhat the senior of 
Vesalius, but may be numbered among his contempo- 
raries, though in the then limited diffusion of knowledge, 
neither man seems ever to have influenced the work and 
teachings of the other. Vesalius knew of Paracelsus 
well enough, but thought him an impostor or a lunatic. 
It is hard to say how much of anatomy was familiar 
to Paracelsus, but much or little, he thought poorly of 
it. He was an alchemist or chemist through and 
through ; and casting to the winds the teaching of the 
regular schools, he preached that diseases should be 
known by the name of the drug which cured them, not 
by titles founded on anatomy or symptoms. It is need- 
less here to enlarge upon the system of Paracelsus, — a 
system resting on metaphysics and distorted conceptions 
of the nature of physical and spiritual forces. Suffice 
it that he believed these forces could be controlled and 
directed by properly selected drugs, and so it was to 
the discovery and employment of these drugs that he 
turned all the vigor of his impetuous and errant genius. 
It was a wild and disorderly life with a tragic end, but 

1 Edward Barry,. "A Treatise on a Consumption of the Lungs." 
London, 1727. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 11 

it left its impress upon the thought of the day, an 
impress which was to expand vigorously fifty years later 
into a famous school of physiology, of which Van 
Helmont became the corner-stone. 

Paracelsus believed that behind the functional pro- 
cesses of organs in the human body, there was an 
Archeus, or imaginary entity, an intelligent vital prin- 
ciple ; indeed, he thought there were numerous such 
entities in the body, some subordinate to others. This 
thought was also in the mind of Van Helmont ; though 
with wider knowledge and deeper learning, he was not 
guilty of the absurdities and excesses of his forerunner. 
He was a man of fine mind, accurate and careful in his 
work, and many of his methods and observations would 
not be unworthy of present-day observers. But he was 
a mystic as well as an observer. He invented the term 
Bias, by which he meant something quite similar to 
Archeus, but he also invented the word Gas, and in that 
he showed himself the rational chemist. Chaos, gas ; 
the similarity in sound suggested the latter word. Car- 
bon dioxide is evidently what he meant, and his investi- 
gations into fermentative processes led him far along 
the lines of modern chemistry. When he comes to con- 
sider digestive processes he breaks away from the old 
idea of the liver with its natural spirits, the heart with 
its vital spirits, and the brain with its animal spirits. 
Be they as they may, and he denies them, he demon- 
strates for our benefit and for the first time that there 
is an acid ferment in the stomach. His conception of 
the source of this " menstruum " was definite enough. 
He asserts that it is prepared in the spleen and not in 
the stomach itself. It is from the spleen, he says, that 



12 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

the stomach draws all its energy. This he says, casting 
aside the clear reasoning of Vesalius ; and Malpighi had 
not yet written (1621). So he goes on to describe vari- 
ous stages of digestion, six in all, and all of them de- 
pendent upon some form of fermentation. There was 
the acid fermentation of the stomach. Then there was 
the digestion in the duodenum, " through a more excel- 
lent vigor of transmutation." This he states, though 
ignorant of the pancreatic juice. After that he de- 
scribes sundry other digestions ; in the liver, in the heart 
and arteries, and in the various tissues of the body. 

Now there were three notable conceptions in the 
writings of Van Helmont, which mark an important 
advance ; he showed that many of the vital processes 
were chemical in their nature and were not merely 
mechanical, as Borelli taught ; he asserted that certain 
of the changes taking place are of the nature of fer- 
mentation, and he discovered carbonic acid gas and 
other gases, which years afterward came to be recog- 
nized as factors of the first importance. 

The work of Franciscus Sylvius (Francois Dubois, 
1614-1672) was an important supplement to that of Van 
Helmont. This Sylvius is not to be confused with that 
Jacobus Sylvius, of "fissure" fame, — the sixteenth- 
century anatomist who was the master of Vesalius. 

During the era of Franciscus Sylvius, men were exer- 
cised by the discovery made by Gaspar Aselli of Cremona, 
in 1622, of the lacteals ; by the demonstration of the tho- 
racic duct of Van Horn in 1652, and by Olaus Rudbeck's 
(Upsala) exhibition of the course of some of the lym- 
phatics. Now Sylvius was a man of much the same 
training and experience as Van Helmont, — a physician, 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 13 

anatomist, and chemist, — but he was a clean-cut practical 
person, free from mysticism. The discovery of the true 
function of the heart and the circulation of the blood 
which Harvey had announced in 1628 had been ignored 
by Van Helmont, but Sylvius appreciated the impor- 
tance of Harvey's work, and much of his teaching is 
founded on that appreciation. He believed in the les- 
sons of chemistry as he saw them, he looked for no 
occult spiritual agencies to explain vital phenomena, 
but asserted that the chemistry of living things is the 
same as the chemistry of so-called dead things ; and 
working at his desk with salts, acids, and bases, he con- 
cluded that the chemistry of the living body might be 
explained by the same laws as governed his laboratory 
reagents. He had other advantages over his predecessor, 
for he knew not only of the gastric juice and bile, but 
of the secretions derived from the salivary glands and 
the pancreas. Sylvius's explanation of the actions of 
these various agents in promoting " effervescence " is 
far from satisfactory to the modern physiologist, but 
he saw that they did exert a definite action which bore 
an important relation to the digestion and assimilation 
of food. 

So we have seen how by the middle of the sev- 
enteenth century, through the study of physiological 
phenomena, two distinct lines of thought, or schools, 
had arisen to explain the nature of digestive processes. 
The two leading exponents of these thoughts were the 
contemporaries, Borelli and Sylvius. Borelli explained 
the phenomena on purely mechanical grounds, and his 
fellow-believers formed the iatro-physical or mechanical 
school ; Sylvius assigned to chemical action alone the 



14 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

results observed and was the leading teacher of the 
iatro-chemical 1 school, and there for many years the mat- 
ter rested. Other teachers, indeed, arose, but their 
influence made for little true advance. Notably there 
was Stahl, of Halle (1660-1734), a very able and inter- 
esting man, who recognized the value of both Borelli's 
and Sylvius's contentions, but taught that granting their 
claims, there remained behind all a " sensitive soul " 
essential to both mechanical and chemical actions as 
exhibited in the living body. So the term " animism " 
arose, with Stahl as founder of that philosophy. 

It is interesting to note how an English writer, 
Barry, 2 early in the eighteenth century sets forth for 
us such knowledge as he saw fit to accept in his 
day. 

" Sylvius rav'd of his Duumvirate, and carried the 
Colluctations excited in the Duodenum from a mixture of 
an acid ^pancreatic juice and an alkaline Bile into the 
Blood, and endeavored to account not only for Diges- 
tion but for most diseases and their methods of cure, 
either from these effervescencies being too intense or too 
languid. These notions prevailed for a long time, and 
producted fatal errors, till they were at length exploded 
by greater Improvements in Anatomy and ChymistryP 
Then he goes on to assert that the vasa hrevia in the 
chylopoietic bowels receive a humor from the stomach, 
but that this humor is neutral ; that no acid is pro- 
duced in the stomach, but that whatever acid is there 
is due to the fermenting remains of food. To counter- 

1 taTpos = a practitioner of medicine. 

2 Edward Barry, M.D., " A Treatise on a Consumption of the Lungs, 
with a Previous Account of Xutrition." London, 1727. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 15 

act the effect of this, Elix. Propriet. Tart. 1 was to be 
given, and aromatic bitters, said to contain a volatile 
salt of a nature opposed to acids, and therefore use- 
ful to quiet this form of indigestion and promote an 
appetite. 

However that may be, he goes on to show that after 
all it is not the stomach which plays the leading part 
in digestion. Indeed, most of the students of the 
seventeenth and early part of the eighteenth century 
regarded the stomach as a rather subordinate organ in 
the digestive process. To both schools it seemed a sort 
of useful reservoir ; for the Borelli folk it did some 
grinding, for the iatro-chemists, some fermenting, but 
the great interest for both schools lay in the intestines 
and in the tissues of organs. Barry says, " beside 
these causes already mentioned, it is probable that the 
chyle is impregnated in the stomach and intestines with 
a great Quantity of animal spirits ; for there is an un- 
common distribution of nerves to these parts and much 
greater than seems sufficient for their muscular 
motion/' 

Such in brief fashion was the state of knowledge 
regarding the digestive organs until we come down to 
the time of the famous Boerhaave (1668-1738) of Leyden, 
and his more famous pupil Haller (1708-1786) of Bern 
and Gottingen. Both of these men are figures so im- 
portant in our studies that they must have passing 
mention ; indeed, Haller's researches were so exact and 
convincing, with the light he had, that little more, 
beyond occasional speculation, was added to exact 

1 " Elixyr Proprietatis Paracelsi " is similar to our modern Tinctura 
Aloes et Myrrhae. 



16 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

knowledge of the subject until two generations had 
passed. 

Boerhaave was an incessant worker, hungry for learn- 
ing, a clear-headed judge of the value of existing knowl- 
edge, and a magnetic teacher of men. He was too 
well rounded to be led away by theories and systems, 
and though he added little of value through original 
research, he collected and expounded the best that had 
been done up to his time, winnowing the chaff and 
throwing clear light on what was salient in the science 
of his day. Thus he appreciated, and, with proper pre- 
cautions, taught the best that he had learned from both 
the iatro-physicists and the iatro-chemists. He under- 
stood that the digestive apparatus is the boiler which 
drives the organic machine, and that its chemical ac- 
tivity and its integrity and correct mechanical action 
are equally important for the creation of the energy 
required. 

Of Haller, the great Swiss physiologist, it would be 
pleasant and profitable to say something more than a 
mere word, did time and space allow. As Foster says, 
" When we turn from any of the preceding writers on 
physiology and open the pages of Hallers *' Elemental we 
feel that we have passed into modern times." He re- 
views the phenomena of the living body, he describes the 
anatomy, gross and minute, the physical properties 
of organs and their chemical composition so far as 
known. He records his own observations and those of 
others, and finally, with all these data clearly before 
him, he draws logical conclusions from the ascertained 
premises. 

Hallers opinions on digestion concern us now, and 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 17 

briefly they are these : Saliva is neither acid nor alka- 
line, and is useful merely as a solvent to help deglutition. 
Of importance is the stomach digestion ; in the stomach 
is the tunica villosa, from the glands of which mucus is 
secreted, the true gastric juice coming from the arteries. 
He takes no account of a nervous fluid which had been 
said to aid in gastric digestion, and therein he differs 
from Boerhaave and the older writers. He looks upon 
the gastric juice as neutral in reaction, and, like Barry, 
asserts that whatever acid is present is a token of the 
degeneration of digested food, for the characteristic of 
living animal tissues is alkalinity, not acidity. Tritura- 
tion by the muscular action of the stomach he regards 
as important. 

Following Malpighi, he asserts that bile is derived 
from the liver, not from the gall bladder ; it is a neutral 
fluid, with the power of emulsifying fats, and so dis- 
solves the chyme of the stomach into the chyle of the 
duodenum. He recognizes value in the pancreatic juice, 
though its digestive properties are not entirely apparent 
to him. 

Important as were these conclusions of Haller, they 
were, of course, far from final, and for nearly a hundred 
years thereafter the processes of digestion continued 
subject to study and discussion by many ingenious ob- 
servers. De Reaumur (1683-1757) in 1752 published a 
paper 1 in which he demonstrated that the gastric juice 
dissolved various kinds of food, and by a process quite 
opposed to putrefaction. Spallanzani (1729-1799), by 
a large number of original and daring experiments, 
such as swallowing and withdrawing sponges, con- 

1 Memoirs of the Academy of Science of Paris. 
c 



18 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

firmed these observations ; and though he failed to rec- 
ognize the essential acid present, he showed beyond 
peradventure and established beyond subsequent doubt 
the fact of the solvent power of gastric juice in 
itself, without the intervention of putrefaction or any 
known form of fermentation. These men went far 
beyond the teachings of Stahl and the earlier physi- 
ologists, who called in to their aid an " archeus "or a 
" sensitive soul " to stand behind and explain vital 
phenomena. It is instructive and somewhat surprising 
to see John Hunter, whose conclusions regarding gastric 
juice were essentially those of Spallanzani, still harking 
back to a coincident and essential underlying cause, to 
which he assigned the title "vital principle." 

Let us observe the situation, as it developed itself 
one hundred years ago, seized upon and explained by 
a young American physiologist, Joseph Glover, who 
published his thesis in the year 1800. 1 

The thesis is carefully prepared ; all available authori- 
ties are cited, for his reading seems to have been wide 
and judicious ; and the conclusions of others are sub- 
mitted to the test of numerous ingenious experiments 
of his own. 

After describing with much accuracy the anatomy of 
the parts, he agrees with Barry that the heat of the 
stomach is essential to proper chemical action, but that 
there is no actual gastric cooking done, as Blumenbach 
had claimed. 

Trituration, too, as an essential in human digestive 

1 Joseph Glover, " An Attempt to prove that Digestion in Man de- 
pends on the United Causes of Solution and Fermentation." Philadelphia, 
1S00. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 19 

processes, he discards, for he regards the muscular 
mechanism of the stomach as a sort of dumb-waiter 
only — useful to push along its burden. 

So this is his conception — food is ground in the 
mouth and mixed with saliva, which acts as a lubri- 
cant; and the saliva, when finally in the stomach, has 
the property of promoting both fermentation and pu- 
trefaction. 

Gastric juice, obtained by killing dogs and by self- 
induced vomiting, he finds to be a colorless, turbid fluid, 
without taste or smell, very similar to saliva in appear- 
ance, so that, quoting the experiments of Barry, Haller, 
Spallanzani, Scopoli, Hunter, and Rush, he " thinks it 
appears sufficiently clear that an acid does not exist 
naturally in the gastric juice." But, he goes on to say, 
basing his opinion on the records of others and on his 
own experiments, the gastric juice is quite capable of 
digesting all species of animal and vegetable food ; and 
he observes that, according to Jacquin, Spallanzani, and 
others, the gastric juice of itself has little tendency to 
either fermentation or putrefaction ; but when mixed 
with other substances its effect is rather to retard those 
processes. 

Like most of the writers of the period, he has a good 
deal to say about the mucus of the Primes Vice, which 
he regards as a lubricant rather than as a solvent. 

Then, there is the bile : he has some rather feeble 
ideas of the bile. He says it is composed of : « 1. A 
coagulable lymph ; 2. A resinous matter ; 3. Animal 
gluten ; 4. Soda ; and 5. A coloring matter which is 
believed to be iron." He proceeds to remark that bile 
is not miscible with fats and oils, but that it neutralizes 



20 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

acids, separates the chyle from the chymous mass, exter- 
minates the fixed air from the alimentary canal, dis- 
solves accumulated mucus, stimulates peristalsis, and 
acts generally as a valuable antiseptic. So it will be 
seen that he grasps at some of the functions of the bile, 
but misses the first and most important, — its action in 
assisting the digestion of fats. 

As to the character and action of the pancreatic juice, 
our ingenious American is very much in the dark, but 
he is in good company. He begins by describing the 
gross appearances of the gland, — the uses of the micro- 
scope were evidently known to him, — and remarks that 
its secretion is very like saliva ; noting ingenuously that 
its duct "has very properly gotten the name of the 
pancreatic duct." He was a keen observer, however, 
and described the supplementary duct of Santorini. 
As to the function of the pancreatic juice he is not 
clear, observing that the pancreatic juice attenuates 
the bile, dilutes the chyme, and assimilates it to an 
animal nature. 

From all these premises our essayist briefly draws 
two conclusions : that the solution of food is the 
first and most important action of all these juices of 
the body ; and next, that this dissolved mass is then 
readily fermented by the action of the digestive secre- 
tions, especially by those of the stomach. 

It is all very ingenious, when we consider the lights 
he had upon his problem, and not the least interesting 
part of the essay is the description of numerous ex- 
periments on animals and on human beings, experi- 
ments which would not be altogether unworthy of the 
modern physiologist. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 21 

Next we come to the nineteenth century, and are 
upon the threshold of that expanded method and 
knowledge of which Bichat was the prophet, during 
the very years in which Rush and his pupil Glover 
lived and wrote and in which Spallanzani died. 

Much had been done to explain the gross anatomy of 
organs, something of their minute structure had been 
studied. Physicists had exploited mechanical possi- 
bilities, claiming all where little was needed ; chemists 
had assigned to ferments and to obscure vital forces the 
phenomena observed ; and judicious physiologists had 
reconciled the best learning of all the schools. So in 
a fashion, out of much nebulous discord, appreciation 
of the nature of digestive processes at last was beginning 
to take form ; but in the study of disorders of diges- 
tion, of the nature of pathological changes, and last of 
all, of logical measures for the relief of sickness, chaos 
still reigned. 

It would be fruitless here and now to rehearse the 
many vague old notions of the nature of digestive dis- 
orders. Some of the knowledge founded on post 
mortem findings and experimental research on animals 
was final and good, much more was immature and bad, 
and still more, again, was the result of metaphysical 
vaporings and the theories of the masters. But the 
clinicians were not mean practitioners. Though their 
diagnoses were amazing, their senses were highly trained, 
and their prognoses were shrewd and reliable. What 
then, since the days of the ancients, had been their thera- 
peutic improvements in the treatment of these abdominal 
disorders ? Truly of the most meagre kind. 

Valentine and Paracelsus had indeed preached that 



22 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

drugs should be employed to secure the chemical reac- 
tions required, and their belief, in halting fashion, had 
secured some few rational results ; but mostly through 
all time, and even until our own day, dosing had been 
based on clinical experiences, — empirical therapeutics 
was universally followed. We took note in passing 
that among the ancients exercise, bathing, emetics, and 
cathartics were the measures employed to keep the 
body in good condition and to relieve digestive distress. 
Hippocrates credited black bile with being the offending 
agent in all these troubles. He gave vinegar to dissolve 
it, and hellebore as an emetic. His cathartics were 
mezereum, rhamnus, elaterium, colocynth, scammony, 
and aloes. Opium was used to quiet pain, and Atrqpa 
mandragora. These were the drugs and such were 
their uses for hundreds of years. Galen's materia 
medica did not differ essentially from this, and his 
theory of pathological changes was no more rational. 
So it went on through the Middle Ages. A few new 
drugs were added to the list, especially some of the 
metallic compounds ; but clinical experiment ruled 
always, and the treatment was of symptoms largely. 
Paracelsus believed that there was a specific for each 
disease, and he used mercury for syphilis ; but we have 
seen that he ignored anatomy, and of diagnosis he 
knew nothing. 

The humoral theory died, specific drugs were sought, 
— there was cinchona, discovered to be the panacea for 
malaria, — and out of the studies of the iatro-chemists 
came certain obvious remedies for "acid stomach" and 
the like ; but of accuracy in prescribing there was as 
yet no sign, because as yet accuracy in diagnosis was 
unknown. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 23 

For many years before the teaching of Boerhaave and 
Haller, — indeed, since the days of Paracelsus, — there 
had been evident a simmering discontent with the thera- 
peutics of digestive diseases and a marked divergence 
in the views of the chemists and physicists ; the for- 
mer seeking and claiming correctives and panaces ; the 
latter, though using drugs of a stimulating nature, such 
as tinctures and bitters, still assuming an attitude of 
more or less scepticism. This was to be expected 
from men who believed digestive processes to be of a 
mechanical nature only. When the more accurate re- 
searches and teachings of Haller and his followers came 
to prevail, the general confidence in drugs was restored, 
to a great extent. Such clinicians as Cullen, Brown, 
and Rush went so far as to claim almost miraculous 
results from their measures, and to point out the im- 
mense improvements made in their own time ; but it is 
a significant fact that these men and others were the 
advocates and founders of schools of nosology and thera- 
peutics, that they differed from each other more or less 
widely in their teachings, that many of them nourished 
by fitting their facts to preconceived theories, and that 
they disputed the claims of their rivals. In other words, 
there was no uniform and accepted basis of scientific 
thought in therapeutics, for the science of rational 
pharmacology was not yet born. Autopsies were rare, 
except for the investigation of dire conditions ; the ab- 
domen in the living practically never was opened ; 
diseases of the liver, bile-ducts, stomach, intestines, 
and pancreas were a terra incognita almost ; gall-stones 
and malignant growths were occasionally recognized, and 
there accurate knowledge ceased. 



24 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

As we come down into the nineteenth century, it 
is instructive to see how our scientific grandfathers 
struggled to make the new conceptions of physiological 
processes and the knowledge derived from animal experi- 
mentation fit in with the new conceptions of chemistry. 
Chapman, 1 the famous Philadelphia teacher, writing in 
1827, remarks : " To trace the multiplied relations of 
medicine to disease, the exercise of the higher faculties 
of the mind is demanded, and we at once introduce the 
spirit of speculation, or what is termed reasoning, in 
medicine. 

" Nothing has been more prejudicial than the abuse 
of this noble prerogative. Consulting the records of 
our science, we cannot help being disgusted with the 
multitude of hypotheses obtruded upon us at different 
times. Nowhere is the imagination displayed to greater 
extent — and perhaps, says an eloquent writer, so ample 
an exhibition of the resources of human invention 
might gratify our vanity, if it were not more than 
counterbalanced by the humiliating view of so much 
absurdity, contradiction, and falsehood." 2 

When we remember that Chapman died within the 
memory of many men now living, and wrote more than 
twenty years after the death of Bichat, his attitude 
toward the subject of our study is surprising, but it 
reflected with much accuracy the opinion of his time. 
He vehemently asserts that if mere experience and 
accurate observation are to prevail, the well-trained 
nurse might be brought to excel the most accomplished 

1 Nathaniel Chapman, 1780 to 1853. 

2 Nathaniel Chapman, " Elements of the Therapeutics and Materia 
Medica," Vol. I, p. 46. Philadelphia, 1827. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 25 

physician ; for our practice would become a blind rou- 
tine, without reason or reflection, and medicine, instead 
of being studied as a science, would become a mere 
mechanical art, exercised only as a vulgar trade. " As 
well might we compare the mere flutterings of the 
meanest and the most grovelling bird with the bold 
and well-sustained flight of Jove's own imperial eagle, 
as those slow processes of a vulgar intellect by which 
facts are collected or observed, with the vigorous sallies 
of speculative genius, which seize truth, as it were, by 
intuition, and reveal it in a burst of light of celestial 
brightness." Still, we are told, that while we laud 
theory, we must not altogether despise the humbler 
employment of observation and experience, for we 
must remember that before we can raise the edifice the 
materials must be supplied, which can only be done 
by the unwearied exertion of this inferior species of 
diligence. 

" Nor is it true, as has been commonly thought, that 
a precise acquaintance with the vital principle is indis- 
pensably necessary as a prerequisite to the advance- 
ment of our science. The nature of a principle may 
remain inscrutably concealed and still the law of its 
action be perfectly determined. Of this, the modern 
or inductive philosophy affords many striking proofs, 
in the specimens of its more splendid generalizations. 
Availing ourselves of the privileges we possess and 
animated by the noblest impulses, let us cordially co- 
operate to give to medicine a new direction and at- 
tempt those great improvements which it so imperiously 
demands. Even if we should not arrive at that point 
of absolute perfection which has sometimes been, per- 



26 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

haps too sanguinely, predicted, we may at least, by 
infusing into the science the genuine spirit of reason 
and philosophy, render it richer in glory and more 
fruitful in benefits to mankind." 

This curious commingling of logic and error, of opti- 
mism and exaggeration, you will find to be common 
enough in that generation. Rush and Cullen so 
wrote a few years earlier, and even Gross strayed in 
the same direction forty years later ; but with such 
fine writing and assurance we have less and less to 
do as time goes on. 

Taking up the question of the physiology of organs 
and the action of drugs, Chapman plunges on with calm 
conviction. He tells us that if there is any one thing 
admitted on all sides, it is that the operation of medi- 
cines does not depend on any of the common laws of 
matter, but on a principle, obscure and unfathomable, 
incident to vitality alone. 

" Medicamenta non agunt in Cadaver," 
a piece of bad Latin which is doubtless true, but does not 
prove his assertion ; and he quotes with approval Will- 
iam Hunter, who said that the stomach has a chemistry 
of its own and carries on processes totally unlike those 
of the laboratory. 

When we remember the generous enthusiasm and real 
eminence of Chapman, it seems unfair to cite his mis- 
conceptions at too great length ; but his arguments were 
those of his contemporaries and illustrate the history of 
the times. For instance, he tells us 1 that to reach the 
circulation medicines must pass either by the lacteals or 
lymphatics, for he disbelieved entirely in venous absorp- 

i Vol. I, p. 54. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 27 

tion. Mr. Hunter had disproved this antiquated doctrine 
of venous absorption, he says, " yet I do not doubt of the 
existence of absorbents, of the nature of lacteals, which 
arising in the intestines, terminate in the portal circula- 
tion." And he goes on to show how the medicines are 
so neutralized by the " preparatory processes of animaliza- 
tion " that they are deprived of all activity. Chyle is 
chyle and blood is blood ; the two are quite similar in 
composition and are quite uniform in quality, regardless 
of what drugs you may pour into the stomach. So it 
was clear to him that the process of assimilation, no 
matter how performed, reduces all substances to a homo- 
geneous fluid, but when thrown into the secretions or 
excretions, being outside the control of vital energies, 
chemical affinities are sometimes again brought into 
play, and here the substances, be they drugs or what 
you will, are in part or wholly regenerated. This ex- 
plains to him how certain substances are to be found in 
distant parts, but cannot be found in the blood flowing 
to those parts ; as garlic in milk, sulphur in sweat, etc. 
Certain it is, he continues, that even the mildest fluid, 
as oil or pus, cannot be injected into the blood-vessels 
without occasioning the most fatal consequences. 

Chapman admits, however, that the whole subject is 
shrouded in mystery, uncertainty, and doubt ; he quotes 
Lee, Everard Home, Caldwell, and Brodie to show how 
the opinions of the best men differ and how the evidence 
is accumulating that drugs do not act directly through 
the blood, but by means of some obscure chemical or 
sympathetic reactions as yet unknown to us ; and in 
order to illustrate the untrustworthiness of the best 
observers, he cites Boerhaave as stating "that he once 



28 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

saw with his own eyes, and hence could not be deceived, 
in the semen of a ram, the germs of the future animal 
following each other exactly like a flock of sheep enter- 
ing a pen." 

We need not pursue this subject further, for Chap- 
man published on the eve of some of the important dis- 
coveries which illuminated and gave a new impetus to 
the whole question of the physiology of digestion. 1 

It is the fashion of writers to assert that modern 
scientific thought began with Vesalius or Paracelsus or 
Haller or Morgagni or John Hunter or Bichat or some 
other, according as such writer's interests and studies 
prompt. As a matter of fact, no man may say when 
scientific thought began, and Huxley tells a story which 

1 The extraordinary self-confidence of the men of Chapman's time, 
and a little earlier, is illustrated by the following quotation : Speaking 
of Benjamin Rush, " His own sublime faith in the treatment (of yellow 
fever) is shown by this entry in his note-book of September 10, ' Thank 
God ! out of one hundred patients whom I have visited or prescribed for 
this day I have lost none.' 

" That is the sort of thing which runs through his writings. It is that 
sort of joyous and enthusiastic optimism which gives pause to the modern 
observer, with his exact methods and his critical and sceptical mind. 
What, pray, is one to believe if Rush could write such stuff as this, which 
implies, if it does not assert, that he had found the certain cure for yellow 
fever? 

" Yet that was his genuine belief. The credulity of those men was 
often thus manifested, and in another place Rush himself tells us that 
1 The pulmonary consumption . . . even when tending rapidly to its 
last stage has been cured by bleedings, digitalis, and mercurial salivation ; ' 
' Gout has been torn from its ancient sanctuary ; ' ' Dropsy is cured; ' ' Teta- 
nus is prevented by inflaming the injured parts, . . . and often cured by 
opium, bark, and wine ; ' ' Madness has yielded to bleeding, low diet, mer- 
cury, etc. ; ' and ' The last achievement of our science consists in the dis- 
covery and observation of the premonitory signs of mortal diseases, and 
in subduing them by remedies in their forming state.' " (" A Narrative 
of Medicine in America," by J. G. Mumford.) 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 29 

leaves us to suppose that the inductive method is older 
than history. All those men whom we have named 
bore more than their share in the development of 
science ; many of them were far in advance of their 
times, but though they may have thought on lines 
original with themselves, we may be certain that they 
owed much to their predecessors, and that if they them- 
selves had not lived some others doubtless would have 
been found to do their work. Evolution does not 
depend on any one man or group of men. So in the 
development of our knowledge of digestive processes we 
find lights here and there appearing, but successively 
appearing, — often in unexpected quarters ; at times 
indeed the wheels seem to be turning backward, but 
in the long run progress surely is made. 

Now in the first half of the nineteenth century, while 
for a time it seemed that medical knowledge of all other 
kinds was advancing rapidly, we find but two names 
which stand out conspicuously as exponents of the 
physiology of digestion. Other names there are, to be 
sure, but these two are notable, — .William Beaumont 
(1785-1853), the American army surgeon, and Claude 
Bernard (1813-1878), the French poet turned scientist. 

It was Beaumont, as we know, who treated and took 
into his service Alexis St. Martin, the Canadian boat- 
man with a gastric fistula, resulting from a gunshot 
wound ; and by a long course of careful observations, on 
the lines already tried by Spallanzani, Reaumur, and so 
many others, came to reliable and definite conclusions 
regarding the nature and action of gastric juice. This 
work he did between 1825 and 1832, and he published 
in 1833. First, he established the fact that the active 



30 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

agent in stomach digestion is an acid fluid secreted by 
the walls of that organ ; second, that this fluid is 
poured out only during digestion ; and finally, that it 
acts on food outside the body as well as in the stomach, 
if kept at a temperature of about 100° F. He also 
made other important investigations regarding the 
effects of various stimulants on the secretion of the 
stomach, the rate at which digestive processes take 
place, the digestibility of varieties of food, and on 
numerous similar problems. 

These inquiries of Beaumont made an immediate 
impression, and when in addition to his writing he vol- 
unteered to demonstrate his patient and his method, the 
profession was stirred to an unusual attention and 
interest. 1 

Besides the chemistry of the stomach, Beaumont 
investigated the peristaltic movements of that organ. 
He described them as due to the alternate relaxation and 
contraction of the longitudinal and circular fibres of its 
muscular coat. He concluded that the muscular coat 
begins its contractions when food enters the stomach, 
and acts in such a way that the stomach contents are 
carried first to the left, then down along the greater 
curvature and on to the pylorus. Then the circuit con- 
tinues up along the lesser curvature and so back to the 
cardia, the course being repeated again and again so 
long as any contents remain in the stomach. 2 

1 See letter in Boston Medical and Surgical Journal, Vol. IX, p. 94, 
1833. 

2 By such means he studied the digestibility of various foods and 
established the following table of time required : — 

Pigs' feet .... 1 hour. 

Tripe . . . . . . . . ... 1 hour. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 31 

It would be interesting to follow Beaumont through 
the experiments and text of his book. He was the first 
physician to take advantage of such a rare opportunity 
as was presented to his hand, and although gastric 
fistula has now become a commonplace of surgery, 
Beaumont established and worked out to a satisfactory 
conclusion many of the problems which up to his time 
had puzzled the physiologists. 

Important as were the researches and conclusions of 
Beaumont on gastric digestion, still, he was working in 
a field that had been tilled already ; but at the time of 
his publishing, the even more important question of pan- 
creatic digestion was quite unsolved. It was Claude 
Bernard, some fifteen years later, who gave us our first 
satisfactory explanation of the value of the pancreas, 
and especially as regards its action on fats. We have 
seen how former observers had noted that so long as 
the various forms of food remain in the stomach they 
are unchanged in their essential properties, and are 
merely melted hy the warmth of the stomach and its 
secretions. The fact that chyle differed from chyme was 
set down by the older writers to the action of the bile 
and the succus entericus. Bernard went to work to 
solve the question as to just where the change takes 

Trout 1 hour 30 minutes. 

Venison steak 1 hour 35 minutes. 

Milk (boiled) 2 hours. 

Roast turkey 2 hours 30 minutes. 

Roast beef 3 hours. 

Roast mutton 3 hours 15 minutes. 

Veal (boiled) 4 hours. 

Salt beef boiled 4 hours 15 minutes. 

Roast pork 5 hours 15 minutes. 



32 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

place, by experiments on rabbits, in which animals the 
duct of Wirsung opens into the intestine about eight or 
ten inches below the common bile duct. He fed his 
animals on oily food or injected melted butter into 
their stomachs, when on opening the abdomen he found 
that there was no chyle in the duodenum between the 
biliary and pancreatic ducts, but that it appeared 
abundantly below the orifice of the latter. Above this 
point, also, he found the lac teals empty or translucent, 
while below it they were loaded with white and opaque 
chyle. These conclusions were soon confirmed by the 
experiments of other observers, both in Europe and 
America, and so the true importance of the pancreas 
came at last to be understood, though only within two 
generations of our own time. 

The activities of Bernard in the study of the phe- 
nomena of digestion were by no means limited to his 
work upon the pancreas. The next object of his con- 
cern was the liver, in 1848, 1 and a few years later he 
published his well-known description of the glycogenic 
function of the liver. 

At that time it was supposed by the more enlightened 
physiologists that the liver acted merely as a filter and 
secreted bile. Here was a new, startling, and supremely 
important fact developed. It had long been known that 
sugar was to be found in the organs, tissues, and secre- 
tions of the body. And it had been observed that in 
certain diseased states sugar was eliminated in the 
excretions. But it was supposed that this sugar came 
directly from the food ingested. The experiments of 
Bernard showed that most of the sugar of the body has 

1 " Xouvelle Fonction du Foie." Paris, 1853. 



ANCIENT CONCEPTIONS OF DIGESTIVE ORGANS 33 

an internal origin and he concluded that it appears first 
in the substance of the liver. He was struck especially 
by the fact that sugar may be recovered from the liver 
long after all external sources of supply have been cut 
off. As an experiment he kept two dogs for three and 
eight months upon a diet of calves' heads and tripe. 
They were then killed, when the liver was found to 
contain sugar fully equal in amount to what exists 
there under conditions of ordinary mixed diet. This 
fact of the constant presence of sugar in the liver 
Bernard found to be true in the great variety of verte- 
brate animals which he examined. 

He concluded, also, that this liver sugar closely re- 
sembles other sugars, but is not identical with them, 
and is distinguished by the fact that it readily becomes 
decomposed in the blood ; whereas beet and cane sugars, 
if injected into the veins, are discharged practically un- 
changed and undiminished in the urine ; and milk sugar 
and glucose, if injected in large amounts, pass from the 
body in the same way. By a further series of ingenious 
experiments he showed that the sugar-producing func- 
tion resides in the liver tissue itself, as a liver taken 
from a freshly killed animal, washed thoroughly, and 
laid aside for a few hours will at the end of that time 
be found to have become highly saccharine. 

These observations of Bernard have subsequently been 
confirmed and amplified by great numbers of observers ; 
with the investigations by Beaumont they constitute 
what we may regard as the initial work of the physiolo- 
gist of to-day. 

The technique, the definite purpose of the workers, 
the new chemical knowledge which was brought to 



34 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

bear upon these questions, and the importance of the 
results obtained place Beaumont and Bernard truly 
among moderns ; and with this brief sketch of their 
achievements in the field of physiology let us bring to 
an end this historical review. 






CHAPTER II 
METHODS 

So many have been the devices applied to investiga- 
tions of pathological conditions arising in the abdominal 
region, that it is well at the beginning to consider what 
every one who would study abdominal diagnosis must 
know, in order to secure results which can be depended 
upon. Many of the procedures recommended in text- 
books are laboratory exercises which waste time, 
annoy the patient, and often yield misleading results. 
In the face of clearly marked clinical symptoms there is 
no test furnished us by the laboratory which may not 
be open to reasonable doubt. This is true even of such 
well-marked tests as the Widal reaction and that for 
the bacilli of tuberculosis. 

There is no short route to absolute knowledge of 
abdominal conditions. There are laboratory and 
mechanical aids to clinical diagnosis, but they are valu- 
able only when weighed and considered in their rela- 
tion to the case under consideration. No laboratory 
man can sit at his desk and dispense diagnoses, much 
less prognoses and working hypotheses for lines of 
treatment, without a thorough knowledge of the case 
in hand. In every way the laboratory man is, or 
should be, the assistant of the clinician. On the other 
side, the clinician who appeals to the laboratory man 
to furnish him with a ready-made diagnosis or prog- 

35 



36 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

nosis, is trying to avoid his duty to his patient. This 
is not to be taken, of course, as meaning that the busy 
physician shall not ask the expert microscopist to tell him 
what is present in a specimen of urine ; to ask him 
as to the presence or absence of bacilli of tuberculosis or 
gonococci in a given specimen, or to ask the chemist to 
make for him an analysis of gastric contents. All that 
is quite proper. Even the busiest man will, however, 
find that his own small laboratory will yield him for 
the most part all the practical results he may need to 
ascertain the necessary points in his case. 

The clinical history and observation of a given case 
are by far the most important things in making a diag- 
nosis. Possibly in the case of nervous patients alone 
is there as great a need of a careful study of the 
history as there is in the case of gastric patients ; 
and be assured that it will often take several sittings 
with the patient to get him to tell, with any degree of 
accuracy, the symptoms from which he has been suf- 
fering. The abdomen is so large a region, and ideas 
in regard to it are so vague, while at the same time 
the layman's notions as to indigestion and constipa- 
tion are so indefinite, that accurate statements are hard 
to obtain and must often be sifted and resifted in order 
to get at the facts. On the physician's side, too, there 
is the danger of getting a preconceived idea as to what 
is the matter, and not listening to the patient's account of 
important details which should put him on the track 
of the real lesion. Another source of error in the early 
stages of serious cases is the personal equation of the 
patient. He runs in to see the physician, asks for relief 
of constipation, colic, or indigestion, refuses to stop at 



METHODS 37 

that time for a careful consideration of his case, 
promises to return after his trip to New York or when 
business is a little easier, and does not appear again for 
some weeks, maybe months, and then often with the 
bewildering statement that the medicine did him no 
good. Later you may find out that in the meantime 
he has consulted several other physicians in the same 
way and also all of his friends who are of a prescribing 
turn of mind. The physician must be a well-rounded 
man who can interpret accurately into terms of path- 
ological anatomy the perplexing statements of his 
patient, his own findings in the course of his physical 
examination, and decide what laboratory aids he must 
employ to verify his opinion. 

Therefore, together with the development of the 
receptive discriminating brain, goes the education of 
the hands and the sense of touch ; for on the delicacy 
of this depends much of the physical examination of 
the abdomen. 

Of the aids to diagnosis, first and foremost comes a 
knowledge of anatomy — normal anatomy, the anom- 
alies, and pathological anatomy. In the consideration 
of a given quadrant, or part of the abdomen, there 
should be the accurate picture of the underlying organs, 
the possibility of there being a congenital malposition, 
fortunately rare, and then of the pathological conditions 
which may arise in or about these organs. Next in 
importance will come a consideration whether the 
physician has to do with a symptom-complex, or with 
a condition arising in a special, single organ. The 
uterus, the kidney, the stomach, the ovary alone, may 
give rise to symptoms, and the diagnosis may thus be 



38 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

made easy ; or the symptoms may involve several 
organs and make difficult to determine the best point 
of attack for the relief of the patient. 

There are two errors into which the clinician may 
fall : he may conceive too great a desire to make an 
absolute diagnosis, to narrow all cases down to some 
single lesion, and ignore accompanying pathological 
conditions which are present in other organs ; or, on the 
other hand, he may incline to treat the prominent 
symptoms only, — not searching in some distinctly local 
lesion for the possible underlying cause. The latter 
tendency leads men to treat many definite stomach and 
intestinal lesions as dyspepsia, while the former error 
has brought surgeons, especially gynecologists, into 
disrepute. 

When considering anatomical questions, it is well to 
remember that for descriptive purposes we must divide 
the abdomen into quadrants. (This division should be 
adhered to in record-making rather than the older and 
more complicated and inexact divisions.) From a 
pathological, or rather surgical, point of view we may 
divide the abdomen into the pelvic region, most impor- 
tant in women ; the appendix region, the danger spot 
of young adults ; the kidney region ; and finally the 
region of those complicated anatomical structures cen- 
tering in the duodenum. 

Surgery is no longer concerned merely with the 
repair or removal of obviously diseased organs or parts. 
Through surgery we propose to prevent serious illness 
by the removal of inferentially harmful tumors, ad- 
hesions, and such other trouble-producing foci. 

In the pelvis the anatomical points to be kept in 



METHODS 39 

mind are the relation of the uterus and adnexa to the 
symptoms under consideration. All of these symptoms 
are given in detail in the treatises on gynecology. The 
bimanual examination of the pelvis must be thoroughly 
understood, whether such examination be practised 
through the vagina or rectum. Especially in the ex- 
amination by rectum is it to be borne in mind that 
special information can often be obtained in regard to 
ptoses. In many cases the lax pelvic floor and general 
loss of abdominal tone is shown by the collapsed con- 
dition of the rectum. The examining finger, instead of 
entering a dilated ampulla, capable of acting as a resist- 
ant air cushion, on which the intestines can rest, finds 
its progress blocked by collapsed walls, and often no 
outlet into the sigmoid region is to be had at all. This 
condition is more common in men than usually is be- 
lieved. Often it is accompanied by symptoms similar 
to those seen in women with prolapsed viscera. 

In the appendix region, besides the acute, chronic, 
and secondary inflammatory processes of that organ, 
there may arise tubercular and malignant lesions. Be- 
low, diseased tubes and ovaries may, by adhesions, 
simulate appendiceal symptoms ; while above, the 
nearly related gall bladder and ducts, the diverticulum 
of Meckel, possible mesenteric thrombosis, or strangu- 
lated hernia, all serve to make diagnosis difficult. 

The renal regions, while not so complex or important 
as the two regions just mentioned, have to be taken 
into consideration. Stone and tuberculosis and new 
growths make up, with abscess, the conditions de- 
manding surgical interference; while malpositions are 
common, and may lead to perplexity in diagnosis on 



40 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

account of their relation to the complicated duodenal 
region on one side and to the spleen and retro-peritoneal 
area on the other. 

The great region of diagnostic perplexity, as has been 
several times pointed out, is found in the region of 
which the duodenum is the centre ; and this region lies 
immediately behind the upper portion of the right 
rectus muscle, which, in response to all possible stimuli, 
contracts in such a manner as to complicate further the 
almost insuperable obstacles to diagnosis. 

Secondary changes in the stomach, resulting in dilata- 
tion and prolapse, are looked for to the left of the 
median line. They are easily made out by the use of 
appropriate methods ; but the pyloric portion, where 
by far the greater number of the primary lesions arise, 
with the immediately succeeding portion of the duo- 
denum, into which empty the gall-ducts and pancreatic 
duct, lie in this area, overshadowed by the edge of the 
liver. The difficulties of diagnosis are enhanced by the 
fact that there is a group of symptoms, subjective for 
the most part, which may indicate indefinite pathologi- 
cal disturbance of all these structures. Such symptoms 
are usually called "dyspepsia" by the laity, and often by 
physicians. They include attacks of discomfort or dis- 
tress, amounting at times to real pain, accompanied by 
a sense of fulness and the belching of gas ; while not 
infrequently vomiting is to be included in the list. 
Renal and intestinal conditions, as well as gall-duct 
disease, may further complicate the diagnosis by giving 
rise to a similar train of symptoms. 

This duodenal region is the battle-ground of modern 
surgery, which the progressive operator seeks to conquer 



METHODS 41 

as thoroughly as he has conquered the pelvic and ap- 
pendix regions. In part the surgeon has succeeded 
already, for the problems of surgery of the biliary 
tract are now concerned mostly with matters of minor 
detail in technique. Each organ must be considered 
separately, yet all must be considered together in order 
to arrive at a just conclusion ; and even after a care- 
ful study of the whole field, one may be forced to turn 
to an exploratory operation to find out the exact con- 
dition ; and it must be admitted from the study of 
reported cases that this procedure — nay, even a post- 
mortem examination — at times fails to reveal the exact 
cause of symptoms apparently located behind the upper 
portion of the right rectus muscle. 

In spite of these difficulties of diagnosis, much may 
be learned by a careful preliminary consideration of the 
clinical history, and by the use of the various aids to 
diagnosis which it is possible to bring to our assist- 
ance. 

Fortunately for the general practitioner, these aids 
usually are simple, and can be employed by himself 
alone or by his assistant. Next to the carefully obtained 
and well-considered history comes the physical exami- 
nation of the patient, and a correlating with the symp- 
toms of all the facts found during this examination. 
Then one is in a position to see what further laboratory 
tests may be wanted to clinch the conclusions so far 
reached. 

It seems almost unnecessary to enumerate the more 
important means of physical examination of the patient, 
but they are four in number : inspection, palpation, — 
which includes digital examination of the rectum and 



42 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

vagina, — percussion, and inflation of the stomach and 
rectum. Auscultation rarely may be of service. 

Inspection of the abdomen at once gives certain infor- 
mation as to the general nutrition of the patient ; while 
deformities of the costal border, distention, or retraction 
may show at once the gravity of a given case. The 
appearance of lineae albicantes may alter one's ideas in 
regard to the chastity of the patient ; previously un men- 
tioned operations may be indicated, while lax abdominal 
walls, as well as more particular points, suggesting tu- 
mors and ascites, may appear. By placing the patient 
in a proper light a good outline of the prolapsed or 
dilated stomach may be seen, doing away with the 
necessity of subsequent inflation. Peristaltic move- 
ments may be of great significance, pointing directly 
to the diagnosis. Dilated veins may speak eloquently 
of hepatic disease or portal obstruction. 

It must not be forgotten, in a consideration of the 
causes of digestive disorders, that inspection includes 
a careful examination of the teeth and gums. 

Palpation will go hand in hand, as it were, with 
inspection ; it will confirm the impression of obesity, it 
will make certain that there is the " boardlike feel " so 
characteristic of severe general peritonitis, it will de- 
monstrate the contracted muscle overlying an inflamed 
area. Through a thin-walled abdomen the pulsations 
of the aorta are to be felt, and must be considered as 
suggestive of aneurism or prolapsed viscera. The out- 
lines of the enlarged liver and spleen and of the movable 
kidney, and definite tumors, are thus marked out. Here 
various postural devices are of use to effect the relaxa- 
tion of the abdominal muscles, thus allowing of more 



METHODS 43 

accurate palpation, or the differentiation of tumors of 
the abdominal walls and movable organs from those 
taking their origin from the retro-peritoneal region, or 
from the deeper fixed organs. Therefore, aids given by 
the mechanical procedure of flexing the thighs, with the 
patient on his side or in the " knee chest," " hands and 
knees," positions must not be forgotten any more than 
the examination by the vagina and rectum in appro- 
priate cases. Complete relaxation may be obtained 
by immersing the patient in a hot bath. Smoothness, 
hardness, roughness, and elasticity of presenting parts 
are all to be noted carefully, and waves made by free 
fluid or splashing within the stomach and intestines are 
to be recognized. 

Percussion, rightly employed, will tell much as to the 
outlines of the organs both solid and hollow, as well as 
the shifting dulness of ascites and unusual tympany of 
gas above the liver. 

Except for particular search after the placental bruit 
and the fcetal heart, and for sounds in the large vessels, 
but little can be ascertained with the stethoscope ex- 
cepting gas movements within the intestines. 

The fourth method of investigation is inflation of the 
stomach or rectum to give accurate information as to 
the size and situation of the stomach or colon. There 
are two ways to accomplish this in the case of the 
stomach, — by means of gas or by the stomach tube. 
To use gas from twenty grains to a teaspoonful of bi- 
carbonate of soda are administered in part of a glass of 
water, immediately followed by a slightly less amount 
of tartaric acid, also dissolved in water. To each dose 
simple elixir may be added to make it palatable. 



44 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

This procedure will enable the observer to obtain the 
outlines of the stomach when, for any reason, passage 
of the stomach tube is undesirable, for the tube is un- 
conquerably disagreeable to some people ; but the 
tartaric acid method has its dangers. The stomach 
tube, to dilate the organ, can always be utilized after 
the removal of a test meal. This can be accomplished 
quickly by blowing down the tube through a clean glass 
mouthpiece or by means of a bulb syringe. Water also 
can be poured into the stomach until the patient indi- 
cates his desire to have the process stop, when the 
amount is noted as it is siphoned off. The distention 
with air should not be carried beyond the point of dis- 
comfort to the patient. During the examination, the 
dilatation of the stomach is maintained by sharply 
kinking the tube, and after the manipulation all the air 
should be expelled by pressure on the stomach before 
the removal of the tube. 

In dilating the large intestine, although it can be done 
with the short rectal nozzle of a Davidson's syringe, 
it is best to use a soft rubber rectal tube. The percus- 
sion outlines of the abdomen are to be known before 
beginning this procedure, and it is well to watch the 
distention carefully, for prolapsed organs may lie in 
practically normal positions when the colon is fully 
dilated. By this means the relation of the bowel to 
other organs and new growths is made out. The 
ordinary position of the intestine, whether normal or 
M-shaped, and the size of the sigmoid flexure become 
obvious. 

A test meal for the study of the processes of digestion, 
in spite of many explanatory papers and chapters upon 



METHODS 45 

the subject, continues frequently to be misunderstood, 
as well as misinterpreted. What we do, is to admin- 
ister, on an empty stomach, a definite amount of food. 
This is withdrawn at a specified time and an analysis is 
made. The amount of gastric contents withdrawn, its 
appearance, and the results of the chemical analysis are 
then compared with the results obtained from similar 
meals which have been given to persons in health. By 
this means a standard for comparison has been obtained. 

Although a large amount of work has been done by 
specialists in this field, the fact remains that but a small 
amount of this work has given returns of permanent 
clinical value. Indeed, the busy practitioner may make 
all necessary investigations with ease, and draw proper 
conclusions from simple tests. The discouraging part 
to the practitioner is that, after doing what seems like 
a good deal of work, he is rewarded by little new infor- 
mation, and so in his disappointment he is apt to think 
that had he only been an " expert " he w^ould have 
obtained pathognomonic information. The attitude of 
the " expert " is quite the opposite. His study of 
stomach contents is a matter of routine, and he knows 
that he is fortunate, in the majority of cases, if he se- 
cures more than a single bit of information to help him 
make up the mosaic picture of disease which he is con- 
sidering. His greater power comes largely through his 
facility in using a large number of names which express 
slight deviations from the general underlying condition. 

It cannot be asserted too often that any laboratory 
analysis is valuable only when applied to a particular 
case. 

There are two test meals which are of general prac- 



46 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

tical value, the Ewald test breakfast and the test meal 
of Leube. The former is of the more value from the 
point of view of chemical analysis ; the latter, when 
used, is a gauge of the digestive and motor power of the 
stomach under conditions of what would be generally 
considered normal as to both the quality and quantity 
of the food used at a meal. 

The Ewald breakfast consists of a glass of water or 
tea without milk or sugar, and a roll or thick slice of 
bread, given on an empty stomach — usually at an 
early morning hour. (Water, 200 g. or 7 oz. ; and bread, 
35 g. or about 11 oz.) It is not usually necessary to 
wash out the stomach before the breakfast ; if, how- 
ever, stasis is suspected, it should be done. At the end 
of an hour the tube is passed and the stomach contents 
removed, at which time it has been found that under 
the conditions in which this meal is administered (in 
normal acting stomachs) the process of digestion is best 
studied. After the remains of the breakfast have been 
collected, lavage can be done without removing the 
tube, and the stomach may also be distended to show its 
position and shape. 

Observations on the stomach contents that has been 
withdrawn should now be made. First of all, what is 
the amount ? Under normal conditions there should not 
be more than 100 c.c, or three ounces, of fluid recovered. 
If there is more than this amount (150-200 eg.), there is 
probably motor insufficiency or hypersecretion, and if 
more is withdrawn than was given at the meal itself, 
stasis is suggested. In such cases, of course, all quantita- 
tive analysis of the contents is valueless, as such contents 
cannot be compared with those of normal conditions, 



METHODS 47 

but examination should be made for hydrochloric, 
lactic, and other acids. Sometimes, on account of a 
rapid digestion and hypermotility, very little contents 
may remain at the end of an hour. If the stomach 
tube has been properly manipulated, this is a very 
significant observation. 

If there is marked stasis, large quantities of contents 
should be recovered, in which case food from meals 
taken on previous days may be recognized. Next to 
the amount of contents its appearance will cast light 
on the condition of digestion. Much froth and mucus 
indicate a chronic process and tendency to fermentation. 
You may note here a separation of the contents into 
several layers ; above all observe the state of digestion 
of the bread, which may appear as finely divided bread 
and water simply, or as well-digested material which 
one could not recognize as having been bread. The 
presence of foreign material, such as blood and bile, is 
to be noted and its importance considered. Brown 
particles do not always mean digested blood. Fre- 
quently you must resort to the test for hsemin crystals 
in order to be sure of their character. A few streaks of 
bright blood are of no significance. The reaction of the 
stomach contents should be acid, and there should be 
free hydrochloric acid (HC1) present. 

The clinician will immediately measure out 10 c.c. 
of the gastric contents and add two to four drops of 
Topfer's reagent (dimethylamido-azo-benzol, 0.5 per cent 
solution in alcohol). A cherry or carmine red will 
appear if free HC1 is present. If the reaction does not 
take place, it will be necessary to try Gunzburg's re- 
agent (phloroglucin, 2 g. ; vanillin, 1 g. ; alcohol, 30 g.) 



48 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

to confirm the observation. Large amounts of acetic 
acid may give so bright a reaction by Topfer's test 
as to deceive the observer ; so if there is any question 
whatsoever, it will be well to make a control experiment 
by using this delicate Gunzburg test for the presence of 
the free HC1. Gunzburg's reagent has to be renewed 
frequently, as it decomposes in a short time. 

Having obtained a reaction with Topfer's reagent, 
and free hydrochloric acid being recognized as present, 
the next question to be answered is, How much is 
present ? This is told by titrating from a burette into 
the same glass which contains the 10 c.c. of stomach 
contents plus the few drops of Topfer's reagent, a deci- 
normal sodic hydrate solution until the red color 
disappears. Under normal conditions 2 to 5 c.c. 
are required to accomplish this, and variations from 
the amount denote hypo- or hyperacidity. From the 
data already obtained preliminary deductions are now 
in order. An absence of HC1 suggests cancer or an 
atrophic condition of the gastric walls. Absence of 
HC1 does not necessarily mean cancer of the stomach, 
for free HC1 may be present late in this disease. It was 
hoped at one time that an absence of HC1 meant the 
presence of carcinoma ventriculi, but clinical experience 
has taught, in no uncertain language, that neither the 
absence of free hydrochloric acid shows that cancer of 
the stomach is present, nor does the presence of free HC1 
preclude the possibility of a cancer. There is no doubt, 
however, that the sudden appearance of gastric symp- 
toms in a patient who is in the cancer period of life, 
there being nothing to suggest a dilated atonic stomach, 
together with the absence of hydrochloric acid, with no 



METHODS 49 

tumor to be felt, certainly increases the probability of 
the case being one of cancer. 

During a recent service of four months in the Male 
Medical Out-patient Department of the Massachusetts 
General Hospital, where it was the custom to analyze 
the stomach contents of all those who presented gastric 
symptoms of any standing, a single instance could not 
be found of increased hydrochloric acid secretion, but 
hypochlorhydria was very common indeed. Poorly pre- 
pared food, irregular hours, and alcoholic drinks ap- 
peared to be for the most part the causative factors in 
such hypochlorhydria. 

Having ascertained the amount of free hydrochloric 
acid in the specimen which is being studied, the next 
move is to find out how much acid has entered into 
combination during the digestive process. For this 
purpose a drop or two of phenolphthalein (1 per cent 
alcoholic solution) is added to the same gastric contents 
from which the free HC1 has been neutralized ; then the 
specimen is titrated with the decinormal sodic hydrate 
solution until a red color becomes permanent. In 
normal cases from 4 to 8 c.c. of the sodic hydrate 
will be used to neutralize both the free and combined 
acids. By this process all the acid constituents are 
neutralized. 

The elimination of lactic acid and the other organic 
acids by appropriate tests makes it sure that the total 
acidity is practically all due to the action of the hydro- 
chloric acid. In order to obtain the percentage of free 
and combined hydrochloric acid, it is necessary to mul- 
tiply the number of cubic centimeters of the decinormal 
sodic hydrate solution by the coefficient 0.00365, which 



50 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

is the quantity of hydrochloric acid neutralized by 
1 c.c. of the decinormal sodic hydrate solution ; 
this gives the amount of actual free hydrochloric 
acid in 10 c.c. of stomach contents, which multiplied by 
10 will give the amount in 100 c.c. of contents, and for 
this the percentage is easily obtained. For the free HC1 
the percentage will range from 0.07 per cent to 0.18 per 
cent, and for the total acidity 0.15 to 0.30 per cent will 
be within normal limits. These figures are stated 
differently by different authors, but broadly a free 
hydrochloric acid contents of 0.1 per cent to 0.2 per 
cent is normal, although the latter figure seems high for 
the American stomach. 

The presence of lactic acid may be a factor in helping 
to make a diagnosis in a doubtful case. It may assist 
and clinch an opinion already formed, but it is by no 
means a pathognomonic sign. Lactic acid is due to 
the fermentation in the stomach of carbohydrate food, 
which is held longer than usual. At the same time 
there must be a low or absent hydrochloric acid con- 
tents in order to allow of bacterial activity in the 
retained food. A bacterial activity is usually present 
in pyloric obstruction, and such obstruction is most 
frequently due to cancer; too much significance has 
been put, in times past, on the value of this lactic acid 
sign. Fortunately, lactic acid is not a normal secretion 
of the stomach, nor is it found after the Ewald test 
meal in sufficient quantity to interfere with the simple 
ferric chloride test. 1 So we see that the presence of 
lactic acid means gastric stasis (from any cause) with 
fermentation. The same may be said of the detection 
1 See also Appendix. 



METHODS 51 

of acetic acid or the fatty acids, except that when 
present they usually denote very complete stasis. 

At times the motor sufficiency of the stomach can- 
not be determined satisfactorily by the presence of resi- 
due in the early morning, nor is the Ewald test breakfast 
a means sufficient to indicate the ability of the stomach 
to secrete free hydrochloric acid. Further distinctions 
are needed, so that often we must resort to a mixed test 
meal. This mixed meal consists of a plate of soup, a 
small amount of meat and bread, or potato, with a cer- 
tain amount of water. This meal is withdrawn from 
the stomach at the end of several hours, when the con- 
ditions of digestion are inspected. The exact details of 
the procedure will depend on whether one follows the 
rules of Leube, of Riedel, or of Ewald. All three authori- 
ties seek practically the same end, but the methods of 
one may be slightly more applicable to a given case than 
those of another. Whichever plan is adopted, it may 
have to be repeated several times in order to meet the 
question which one seeks to answer. 

Possible early information regarding beginning stasis 
may be obtained by fermentation experiments with the 
gastric contents, noting the time in which fermentation 
phenomena appear in a fermentation tube as compared 
with the time required by the contents of the normal 
stomach. If any such test is employed, it must be with 
reservations, as many persons habitually have sluggish 
digestions, — possibly due to some anomaly or patho- 
logical condition, — when, nevertheless, for years and 
years the individual may remain in a condition of good 
health. Should such a person have a gastric upset at 
any time there would be no special reason for alarm on 



52 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

account of finding early fermentation of his gastric con- 
tents. In a person, however, who has experienced a 
craving for food regularly at the end of four or five 
hours after meals, an observation of early fermentation 
would justly excite apprehension. 

Microscopic examination of the stomach contents 
may reveal the presence of yeast cells, sarcinae, and 
other bacteria, as well as blood, and at times even bits 
of cancer or granulation tissue. 

Blood is in all cases worthy of note, whether it be 
vomited or passed by the rectum. This, of course, does 
not refer to small streaks of fresh blood appearing after 
the passage of the stomach tube or after a severe attack 
of vomiting, or after a very constipated movement of 
the bowels. But large amounts of blood mixed with 
vomitus are of importance. Such blood is seen to be 
either fresh or modified by digestive processes. In the 
case of presumably vomited blood it is well to be sure 
that the hemorrhage did not have its origin in the 
pharynx or postnasal cavities. The blood will be 
bright red if vomited soon after being poured out into 
the stomach, but it is soon changed by gastric juice into 
the classic " coffee-ground " condition which is easily 
recognized. Small amounts of brownish material are 
frequently found which give rise to doubt, in which case 
we must resort to the test for haemin crystals or to the 
guaiac color test. 1 

1 Guaiac test : Fresh alcoholic solution of guaiac should be made by 
scraping with a knife a few grains of gum guaiac into a test-tube con- 
taining about 5 c.c. of alcohol, in which the guaiac quickly dissolves. It 
is better to select that portion of the gum guaiac appearing as yellow 
nuggets on the surface. A few drops of peroxide of hydrogen are added. 
The stomach contents or the watery mixture of faeces to be examined are 



METHODS 63 

As to melena, unless in great quantities, blood is com- 
pletely changed in its passage through the intestine so 
that it gives tarry stools. The origin of any unchanged 
blood coming from the rectum can usually be determined 
by a careful rectal examination. 

Small amounts of digested blood in the stools of those 
who are suspected of having an ulcerated process in the 
pylorus or in the duodenum are valuable evidence of 
ulcer or neoplasm. Evidence of such "occult hemor- 
rhages" usually can be found only after careful and 
persistent search. The amount of fat in the stools 
occasionally may have to be estimated to determine 
the intestines' power of absorbing fat. Sometimes the 
faeces must be screened to settle the question whether or 
not pain is caused by the passage of a gall-stone or a 
calculus of the pancreas. 

In persistent diarrhoea the microscope may show in 
the still warm specimen the amoebae coli as the cause 
of the flux ; or after diluting with water, and letting the 
faeces stand for a few hours, examination of the upper 
layer may show bacilli of tuberculosis coming from 
ulcerations of the bowel. 

The Widal reaction, when present in proper dilution, 
points to typhoid fever ; but it must be remembered 
that the reaction sometimes has not been observed until 

mixed in a test-tube with one-third their volume of glacial acetic acid and 
the whole shaken with an equal volume of ether. On standing, the ethereal 
extract, containing the hsemoglobin if present, will separate and occupy 
the upper portion of the mixture in the tube. A few drops of this ethe- 
real extract are next added to the alcoholic guaiac solution, and if blood 
was present in the original material, a blue-violet color should appear in 
the mixture. So delicate is this test that meat in the stomach contents 
will give the blue color. 



54 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

late in that disease, or even until the onset of a re- 
lapse. 

The agglutination reaction of the blood to some of the 
para-typhoid group of bacilli possibly helps to explain 
a run of fever for which otherwise we should have no 
definite name. 

The search for gonococci in cases of salpingitis is a 
useless waste of time for the ordinary clinician. Absence 
of the cocci from the urethral or vaginal secretions does 
not prove that the inflammation is not of gonorrhceal 
origin, nor does their presence mean change of treatment. 

If it is desired to try the tuberculin test, be sure that 
the patient's lungs are carefully examined first of all ; 
and use the X-ray, if possible, to verify the results, be- 
cause it has been demonstrated that the proportion of 
people having some tuberculous lesion is very great, — 
some autopsy statistics putting the percentage as high 
as 98 per cent. It is, therefore, easy to see that by 
means of the tuberculin test a misleading answer may 
be returned to a question of doubtful abdominal tuber- 
culosis, on account of a small lesion located in the lungs 
or other organs. 

In all cases, a urinary examination should be carefully 
made, as experience has taught that sometimes renal dis- 
ease will account for many apparent gastric symptoms 
which often seem so simple as to be called " dyspepsia." 

The finding of pus or blood in any amount in the 
urine will, of course, suggest further persistent search 
for a definite lesion ; and it may, in a few cases, be 
necessary to collect the urine from each kidney in order 
to make sure which kidney is affected. When we know 
that one kidney is diseased, it may be of great impor- 



METHODS 55 

tance to know whether the other is also diseased, or is 
capable of doing the work of both. Finding bacilli of 
tuberculosis in the urine may call for a number of tests, 
including the inoculation of guinea pigs, to make sure 
that these are not simply acid-resisting smegma bacilli. 

The X-ray will be found of value in locating renal 
and ureteral calculi. The best results are to be ex- 
pected in the case of phosphate of lime stones. Under 
favorable circumstances, however, one may discover 
uric acid and calcic oxalate calculi. The X-ray is of 
no other aid in abdominal diagnosis, unless to indicate 
the location of a metallic foreign body. A large aneu- 
rism might be shown on the plate, but probably in no 
manner to give positive indication of its presence if 
otherwise the diagnosis were in doubt. 

An examination of the blood by the quick-staining 
process of Wright 1 will give one a definite idea as to 
the presence of leucocytosis and possible acute leu- 
caemia, — a condition which has been mistaken by 
competent men for an abscess condition. The blood 
examination will also show plasmodia of malaria if 
they are present. Such a discovery has saved patients 
from the operation for appendicitis in cases of malaria 
in which severe abdominal pain had been the most 
prominent symptom. 

In some cases the apparent presence of a leucocytosis 
will make desirable repeated blood counts in order to 
keep track of any leucocytosis as an index of the 
advance of an inflammatory process. However, one 
must bear in mind that leucocytosis or iodophilic 
granules are not infallible guides as to inflammation 
1 Journal of the Boston Society of Medical Sciences for 1903. 



56 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

and perforation of the intestine, but must be carefully 
considered in the light of all the other symptoms. 
When so considered, the presence of these phenomena 
is capable of rendering assistance in many doubtful 
cases. 

Such observations cover practically the solid ground 
in the realm of laboratory aids. Other methods are 
suggested and are being carefully tested by enthusiastic 
workers, and it is hoped that some at least of these tests 
will come under the group that can be relied upon to 
give assistance in the majority of selected cases. 

The methods of examination and laboratory aid given 
above require but little paraphernalia and but a small 
closet laboratory for their accomplishment. The doing 
them in each case, whatever may be suggested by the 
symptoms, and the thinking over carefully of each 
result will enable one usually to approach the correct 
diagnosis. Often, however, it will be found, when all 
has been said and done, that an exploratory operation 
only can settle definitely the vexed questions, and even 
this sometimes will fail to settle them. 

A close attention to symptoms, and the refusal, except 
as a very last resort, to regard definite attacks of pain, 
nausea, and vomiting as nervous and hysterical condi- 
tions, will save a number of cases, or at least will allow 
the physician the mental satisfaction of making a cor- 
rect diagnosis. 



CHAPTER III 

THE STOMACH 

If one takes a file of any of the older medical journals 
which run back for fifty or more years, and looks through 
them chronologically for statements regarding digestive 
disorders, one gets a curiously vivid and instructive pic- 
ture of the development of our present knowledge. The 
Lancet, The British Medical Journal, Virchow's Archives, 
the Transactions of the London Pathological Society, The 
American Journal of the Medical Sciences, and The Boston 
Medical and Surgical Journal have illustrated our theme, 
and in their study certain facts are noticeable : for 
more than half of that time one is impressed with the 
similarity of topics discussed, the infrequency, compared 
to modern days, with which writers mention abdominal 
diseases, and the almost total disregard of the great sub- 
ject of treatment. Clinical histories are there in detail, 
and gross morbid specimens are described ; but for many 
years no new therapeutic instructions of value were 
given. 

Therefore, before entering upon the question of the 
present-day aspects of these disorders, it may be inter- 
esting to consider briefly some of the therapeutic views 
of the subject, so far as we may discover them, held at 
the beginning of our era, — forty years ago, — that we 
may make a comparison between the measures and 
results of that time and those of the present. 

67 



58 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

As regards this matter of digestive therapeutics thirty 
to fifty years ago, a fairly accurate knowledge may be 
obtained from the text-books of the time, as well as 
from the current journals. Take Fothergill's " Hand- 
book of Treatment," which sums up the best of English 
practice ; Flint's " Clinical Medicine," which does the 
same for America ; and Niemeyer's " Practical Medicine," 
the popular German text-book of the time, and you will 
arrive at a very comprehensive knowledge of the views 
on therapeutics held at the beginning of our own era. 

A fact striking to us, with our more curious and 
intimate acquaintance with processes in individual 
organs, is the former universal prevalence of sympto- 
matic treatment, — a prevalence coming down almost 
to to-day. A reading of the text-books might seem to 
refute this statement, for definite, clearly described 
diseases are considered in them, and the appropriate 
treatment is indicated ; but take the journal articles, 
with the records of cases, and you will find that the 
great majority of abdominal diseases were treated with- 
out any clear knowledge of the diagnosis, and that on 
those rare occasions when an accurate diagnosis was 
made and confirmed at autopsy, the complacency of 
the narrator was evident. 1 

Even in the text-books much of treatment is sum- 
marized under such headings as " Digestive Disturb- 
ances," "Dyspepsia," etc., so that to one reading, it is 
not altogether clear whether the writer refers to diseases 
of the stomach, the liver and bile ducts, the pancreas, 
or to conditions associated with all of these. That 

1 Vide Transactions Pathological Society, London, " Fatty Degenera- 
tion of the Pancreas," Vol. XXIV, p. 121. 



THE STOMACH 59 

man would be fatuous indeed who claimed that we are 
now free from such confusion ; but since frequent ante- 
mortem examinations have come to supplement and 
supplant in a measure the infrequent old post mortems, 
our diagnostic accuracy has entered upon a phase previ- 
ously impossible. 

The treatment of symptoms is especially dwelt upon 
by Fothergill, who discourses in their order, interestingly 
and at length, about acute and chronic affections of the 
stomach. He dwells much upon the theory of emetics 
and their value, recognizing the direct agents, mustard, 
sulphate of zinc, sulphate of copper, and others, and the 
specific agents, ipecacuanha and apomorphia. The ad- 
ministration of these drugs was followed by that of 
gentle saline laxatives, and then a carefully regulated diet 
was enjoined until convalescence was established, — all 
of which differs in no essential from the practice of to- 
day. But it was the " permanent conditions " to which 
the acute attack might give rise which troubled and 
especially exercised the ingenuity of men of that time. 
As Fothergill remarks, " Gastric catarrh, ulcer, and 
cancer are affections whose treatment requires great 
consideration and much thoughtful application of phys- 
iological knowledge." 1 So, careful dieting, giving a 
little and often, was the rule then as now, but the 
anatomical conditions present were constantly regarded 
with misgivings and the outlook with uncertainty. 

" When the causes can be removed by proper treat- 
ment," says Niemeyer, " the disease is often cured." 
But the causes are pointed out to be thickening of the 
mucosa and the submucosa, and changes in the mus- 

1 Fothergill, p. 365. 



60 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

cular tissues ; obstruction of the pylorus and dilatation 
of the stomach ; while not infrequently ulcers of that 
organ and of the duodenum are followed by the forma- 
tion of cicatrices, adhesions, distortions, still further 
narrowing of the pylorus, and increased dilatation with 
ptosis. 1 As regards the treatment of chronic gastric 
catarrh and its sequelae, Niemeyer is sufficiently ex- 
plicit. He forbids alcohol, prescribes warm clothing 
and warm baths, and lays down very precise dietary 
rules : lean meat in small amounts, broths, white 
bread, salt or smoked meats, skimmed milk, buttermilk, 
and soda waters, — and he concludes that " the results 
from this treatment are the most brilliant that are 
ever attained in medicine." 

Drugs were little used by the writers of that time, 
as compared with the writers of a previous generation. 
Bismuth and the nitrate of silver were commonly em- 
ployed, but were not greatly relied upon, and no local 
treatment by lavage was attempted. Just what Nie- 
meyer means by calling his results the most brilliant 
ever attained is not at all clear, for he goes on to tell 
of the frequent serious results of this condition, the 
long illnesses, and the sometimes fatal endings. 

The methods then employed in getting at accurate 
facts and end-results of treatment were not the pains- 
taking statistical methods of to-day, so that it is im- 
possible to gain a knowledge more satisfactory than a 
general impression ; but that impression, as one gleans 
it from text-books, essays, and reviews, is not very 
cheerful. 

Gastric ulcer was justly regarded seriously by the 
1 Niemeyer, Vol. I, pp. 495, 496. 



THE STOMACH 61 

writers, though it is evident from the reported autop- 
sies that the correct diagnosis was very frequently over- 
looked — much more frequently than is the case to-day, 
one must believe. 

One of the most interesting descriptions of gastric 
ulcer — a description written nearly fifty years ago in a 
letter from an American student 1 in Vienna — deals with 
the work and views of Johann Oppolzer, whose teaching 
embodied the best thought of the sixth and seventh dec- 
ades of the century on the subject. After discussing 
the various forms of ulcer, their course, symptoms, and 
appearance, the writer deals with the treatment. Rest 
is the main thing, he says. With rest they may be 
healed in six or eight weeks without any medicine ; 
that is a lapse of time somewhat longer than one con- 
cludes to be the finding of Greenough and Joslin, who 
published in 1899. But how to obtain rest ? Food was 
given by the mouth, — a little and often. Milk was the 
great reliance, — sour milk, buttermilk, pure milk ; no 
solid food when there was cardialgia but broths, gruels, 
and ices. Oppolzer thought ill of nitrate of silver, which 
Niemeyer prescribed ten years later. Indeed, the Vienna 
teacher showed that the only indication for drugs was 
to combat symptoms ; for pain, opium and bismuth, 
belladonna, and counter-irritation ; for hemorrhage, 
tannin, sulphate of zinc, acetate of lead, and ice. After 
all, careful dieting was the main reliance, though entire 
abstinence from stomach feeding and the use of nutrient 
enemata were not yet practised. 

The writer noted with interest that chronic gastric 
catarrh and dilatation are often coincident with ulcer, 
1 James C. White, in Boston Medical and Surgical Journal, Nov. 5, 1857. 



62 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

and concluded by observing, « From the frequent occur- 
rence of this disease [ulcer] in Vienna, I am inclined to 
think that many of our cases of < dyspepsia ' might be 
resolved into the same, were we not so easily satisfied 
and blinded by that very unsatisfactory word, a word 
which I never heard used by Oppolzer." All this and 
more of the same kind sounds curiously familiar to 
modern ears. 

When it came to cancer of the stomach, there was 
nothing to be done beyond symptomatic treatment : 
diet as in gastric catarrh, red wine ; the alkaline car- 
bonates or creosote for hyperacidity " due to pyloric 
obstruction " ; aloes and colocynth for constipation, and 
morphia for pain. The point of greatest interest to us 
in these old discussions of cancer is the diagnosis, — its 
distinction from ulcer and chronic gastritis, and the 
question of its becoming implanted upon an ulcer. The 
differential diagnosis was of course difficult, and accord- 
ing to Andral was impossible unless a tumor was felt. 
J. Frank stated that there was no proof of cancer 
springing from ulcer, whether healed or unhealed. 

Aside from the conditions already named, various 
other affections of the stomach are mentioned in the 
text-books ; but they need not concern us except to 
induce the reflection that many of the more obscure 
symptoms, which were classified as " dyspepsia," " ner- 
vous dyspepsia," " cardialgia," etc., were probably due 
in part to visceral ptoses, which were first brought 
clearly to the attention of the profession by Glenard in 
1885, though Virchow and Kussmaul and Oppolzer 
referred to the condition mam^ years before. This and 
kindred matters we must consider later and at greater 
length. 



THE STOMACH 63 

Now there are certain lesions of the stomach in 
regard to which surgical opinion is becoming united in 
affirming that they are proper subjects for operative 
treatment. And internists, too, more and more gener- 
ally are recognizing that in an operation alone lies any 
hope for permanent cure. As yet the lapse of years is 
not great enough to allow of extensive statistics regard- 
ing remote results; but if we can judge by the conditions 
seen three or five years after operation, we are justified 
in assuming that in proper operations, selected carefully 
to fit the individual case, we have a method of treat- 
ment far more promising than anything else as yet 
devised. 

It seems as though the methods followed by internists 
for the relief of gastric disorders had been brought to 
perfection ten or fifteen years ago. Those methods may 
be summed up practically in two words, rest and cleanli- 
ness. Subsidiary means are used, to be sure, — appropri- 
ate diet and drugs ; but the rest and the cleanliness are 
the leading factors, obtained imperfectly often, dis- 
tressfully too, and maintained mostly with difficulty 
or not at all. 

The surgeon also seeks to employ these two methods 
for the relief of gastric disorders, with what measure 
of success we are beginning in these days to perceive. 
The conditions for which surgical aid is employed are 
becoming more numerous, and doubtless will continue 
so to become. Let us then consider some of the more 
important stomach lesions, and, so far as results obtained 
may guide us, try to determine what course to pursue 
under particular conditions. Ulcer or cancer is at the 
bottom of most of the operable gastric disorders ; but 



64 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

for convenience here we may name in this discussion 
(1) Ulcer and its complications, Pyloric Obstruction, 
from whatever cause, Hemorrhage, Distortion of the 
Stomach, Adhesions, Tetany ; (2) Spasm of Pylorus, 
(3) Cirrhosis, (4) Ptosis, (5) Cancer. 

For the sake of the argument, and out of its logi- 
cal order, we wish first to discuss pyloric obstruction, 
prefacing what we have to say with a word on the 
stomach tube, that instrument most useful for gastric 
diagnosis. 

It is surprising that not until within recent memory 
has the stomach tube been used for purposes of diagno- 
sis and for treatment. The stomach tube in connection 
with a syringe was first employed by Philip Syng Phys- 
ick, 1 in Philadelphia, as early as 1800, and came into 
common use there in the first decade of the last cen- 
tury ; but it was regarded as a valuable implement for 
washing out the stomach in cases of poisoning merely. 
It was truly a pump for many years, so that not until 
the siphonage 2 principle was applied to it in our 
own time was its great value for diagnostic and thera- 
peutic purposes revealed. So the stomach tube became 
and remains a weapon of first importance in dealing 
with gastric disorders, and not least in ascertaining the 
extent and gravity of pyloric obstruction. 

The most common immediate sequel of pyloric ob- 



1 " The Discovery and first use of the Stomach Tube by an American 
Physician," Julius Friedenwald, in Johns Hopkins Hospital Bulletin, 
September, 1903. 

2 " The stomach siphon was first proposed by Arnott, in 1829, but 
passed into oblivion. Kussmaul again directed the attention of the pro- 
fession to the stomach tube in his publications in 1867 and 1869." 
C. A. Ewald in " Diseases of the Stomach." 



THE STOMACH 65 

struction is dilatation of the stomach with its resulting 
symptoms. The diagnosis of this condition, the esti- 
mate of its gravity, and the application of appropriate 
treatment are subjects on which the last word has not 
yet been spoken. So long ago as 1869, in his discussion 
of this topic, Kussmaul pointed out how frequently the 
difficulty was a purely mechanical one which surgery 
alone could remedy, and added the fear that his sug- 
gestion " would meet with quiet or outspoken scorn." 
And more than twelve years ago Ewald wrote how his 
experience led him inevitably to the conclusion that 
" operative gastric surgery has a great future before it, 
and perchance the time is not far distant when we will 
excise a lancet or leaf-shaped piece from a dilated 
stomach." 1 

In spite of the long ago conviction of these expe- 
rienced clinicians, their advice came slowly to fruitage 
because the teachers of internal medicine had a theo- 
retical rather than a practical knowledge of surgical 
possibilities, and because only recently have surgeons 
made an independent advance upon this field, having 
overcome the difficulties of the pelvis, the lower por- 
tion of the abdomen, and, to a degree, the problems of 
the bile passages. 

However, to Kussmaul, to Ewald, and to such others 
we owe it that for many years the nature of gastric 
pathological processes has been known, and logical 
remedies applied, so far as might be done without 
resort to surgery. As Ewald says, without the stomach 
tube we should be almost powerless. Through its 
means he has been able fully to substantiate the state- 

1 C. A. Ewald, American edition, 1892, p. 158. 



66 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

ment of Tiedeman and Gmelin (1826) that there is 
normally no hydrochloric acid in the stomach when 
fasting ; a standard of the normal processes of digestion 
has been found, and to this the ability of the diseased 
stomach to assimilate food can be referred. Lavage 
as a therapeutic measure is carried out with the aid of 
the stomach tube, and by it an easy way is furnished 
to distend the stomach with air or fluids in order to 
demonstrate its capacity and position. 

Just what we mean by gastric dilatation is not always 
easy to determine, for stomachs vary normally in 
capacity according to the size of the individual, and 
even in different individuals of the same general pro- 
portions. Says Ewald, " I understand dilatation of the 
stomach or gastrectasis to be that condition of the 
viscus which is accompanied by the clinical symptoms 
of disturbed gastric function due to the enlargement of 
the organ ; and megastria to be the acquired or con- 
genital large stomach, the abnormal anatomical state 
of which is functionally compensated." To quote 
further, " The large stomach may become catarrhal and 
its owner dyspeptic ; but clinically speaking such a 
patient has no gastrectasis although more disposed 
thereto than others. Megastria and gastrectasis have 
frequently been confounded with each other. An en- 
tirely different condition, if I may anticipate, is gastric 
insufficiency, which indeed may and frequently does lead 
to the symptoms of gastrectasis, yet does not have the 
anatomical basis of the dilated stomach, but is a func- 
tional disturbance occurring in the most varied condi- 
tions of size of the organ." 

In this discussion we are not considering acute dila- 



THE STOMACH 67 

tation, a rare and transient affection when survived, 
but rather that more common chronic dilatation fa- 
miliar to all clinicians. 

Pyloric obstruction is probably the most common 
cause of gastrectasis ; the second assigned cause being 
absolute or relative weakness of the expulsive forces. 
To this latter variety belong the cases of so-called 
atonic dilatation of the stomach, in which the extent 
of the dilatation averages much less than when due 
to pyloric obstruction. 1 The increasing light which 
we are getting on this subject, thanks to recent and 
frequent operative exploration of stomach lesions, is 
strengthening our conviction that these atonic dila- 
tations are less common than was at one time sup- 
posed, for very often adhesions, duodenal, hepatic, and 
omental, which account for the symptoms, are found ; 
and these adhesions were not and could not be recog- 
nized before exploration. The scars of small, completely 
healed ulcers too have been found in cases when in life, 
or before operation, a non-anatomical cause had been 
diagnosticated. When undoubted cases of atonic dila- 
tation are encountered, they are probably best treated 
medically ; at least such treatment should be given a 
fair trial. 2 

Although the diagnosis of pyloric obstruction is not 
always easy, it is certainly to Ewald and Boas that we 
owe most for our accuracy and finality in the demon- 
stration of this condition. As will be shown, however, 
from the Massachusetts General Hospital cases to be 
described later, it is by no means true, as Ewald states, 

1 W. H. Welch, Pepper's " System of Medicine," Vol. II, p. 587. 

2 Hartman in Gazette Medicale de Paris, Xov. 15, 1902, p. 361. 



68 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

that as a rule patients with dilatation of the stomach 
are middle-aged or advanced in years. 

If we are to apply the appropriate remedy certainly, 
it is essential always that we ascertain the cause of 
dilatation, — which, after all, is a secondary condition. 
As Ewald most pertinently says, " functional dilatations 
are always of relatively short duration, so that they do 
not lead at all to the classical symptoms of dilatation of 
the stomach, or only do so transiently ; they run the 
course rather of dyspeptic conditions peculiar to the 
special underlying disease of the organ, chronic gas- 
tritis, atony, or the neuroses." 1 

As has been intimated, our present conception of the 
mechanical causes of dilatation is much what it was 
when Oppolzer wrote, but of the relative frequency of 
those causes we know much more. 

Quite recently there occurred in the practice of the 
writers a case illustrating the difficulty of ascertaining 
the conditions present. The patient was a hard-working 
mother of many children ; forty-six years old, thin and 
wiry ; of previously good health so far as she could 
recall. Her illness had lasted about three months. 
She had much distress and pain in the left hypochon- 
drium and epigastrium, nausea and vomiting after all 
food, — even water; she wasted rapidly, and for two 
weeks before being admitted to the Massachusetts Gen- 
eral Hospital was kept alive by nutrient enemata. 
Distention of the stomach with air showed that the 
lower border descended only to the navel ; there was 
no ptosis ; the organ could contain but fifty fluid ounces 
of water. Both free hydrochloric acid and lactic acid 

1 Ewald, p. 122. 



THE STOMACH 69 

were present, but no organisms ; and the residuum was 
about ten ounces. Our supposition was that some 
pyloric obstruction, either malignant or benign, was 
present. Accordingly the abdomen was explored. A 
very slightly dilated stomach was found, but the colon 
and duodenum were seen to be closely adherent to that 
viscus, while the pyloric orifice would readily admit the 
finger tip. The markedly thickened scar of an old 
pyloric ulcer was the obvious primary cause of the diffi- 
culty, but this would have given rise to few symptoms 
had it not been for the position of the duodenum, closely 
adherent to the stomach, so that the pyloric channel was 
sharply kinked at an acute angle. With the increasing 
dilatation of the stomach this angle became sharper and 
the lumen narrower, causing almost total obstruction. 
Freeing the adhesions and a liberal enlargement of the 
canal by Finney's method accomplished a cure. 

This case is cited to illustrate merely the frequent 
difficulty and obscurity of diagnosis in certain cases of 
dilatation. Let us now return to a consideration of the 
causes and diagnosis of pyloric obstruction and allied 
conditions associated with gastrectasis. 

Since the publication of Welch's well-known article, 
twenty years ago, when he stated that cancer was the 
most common cause of pyloric stenosis, the conviction 
gradually has been forced upon us that cancer, though 
very common in this region, probably does not cause a 
majority of these obstructions. The available figures 
seem to indicate that ulcer, with its sequelae, cicatrices 
and perigastric adhesions, plays perhaps the most im- 
portant role. In addition to the two above-mentioned 
causes of obstruction, cancer and ulcer, Osier 1 points 
1 Osier, " Practice of Medicine," p. 494, ed. 1901. 



70 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

out that it is not an uncommon experience to find at 
autopsy instances of dilatation associated with simple 
hypertrophy of the coats of the stomach in the pyloric 
region ; and Boas has dealt with the subject, citing op- 
erative cures, 1 as have a few others. Further, a case 
observed by the present writers — gall-stones, associated 
with marked gastric hyperacidity — was further com- 
plicated by a resulting simple pyloric hypertrophy with 
dilatation ; and in this case, as in other similar cases, 
the removal of the gall-stones resulted in complete re- 
lief of the gastric conditions. The possibility of such 
complications has been dealt with by Kaufmann in a 
suggestive paper and will be again considered by us. 2 
Another not infrequent cause of pyloric obstruction is 
the pressure of tumors from without, among which 
Ewald, Barker, and others have referred to floating 
kidney, though it must be said that the cases produced 
as evidence do not bear critical examination. Then 
there are the rare cases of polypoid growths choking the 
pylorus ; and most interesting is the complete obstruc- 
tion, with volvulus and strangulation, demonstrated on 
the cadaver as possible by Kussmaul, and quoted by 
Welch. 3 Seven cases of this catastrophe are described by 
Spivak. 4 

Welch furnishes a list of twelve causes of gastrectasis, 
under three groups : (#) stenosis of the pylorus or of 
the duodenum, (5) abnormalities of the contents of the 

1 Boas, Archiv fur Verdauungskrankheiten, Bd. 4, § I. 

2 J. Kaufmann, "Gall-stones and Gastric Hyperacidity," American 
Medicine, Nov. 14, 1903. 

8 Pepper's " System," Vol. II, p. 588. 

4 C. D. Spivak, " Volvulus of the Stomach," American Medicine, 
Oct. 31, 1903. 



THE STOMACH 71 

stomach, (c) impairment of the muscular force of the 
stomach. We have to deal mainly with group (a), though 
group (c) may enter into the surgeon's calculations. 

In considering the symptoms of pyloric obstruction, we 
must bear in mind that the gastric dilatation which 
eventually accompanies and follows it is often a late 
manifestation; but until dilatation takes place it is 
rarely possible to arrive surely at the true cause of the 
symptoms, namely, the obstruction. It is a common 
thing to find that those patients in whom gastrectasis is 
developed have complained of a disordered digestion for 
"years," "since childhood," for "as long as they can 
remember " ; and these long-continued symptoms are 
seldom of a trifling or transient nature ; they have 
responded sometimes quickly, at other times very 
slowly, to the ordinary methods of treatment ; and they 
have recurred at increasingly frequent intervals. For 
years the patient has had " spells " of distress, some- 
times after taking food, sometimes relieved by food. 
He has had sour eructations, belching of evil-smelling 
gas, occasionally vomiting of food or of a watery sour 
fluid, sometimes with pain preceding the vomiting. 
Rarely there has been blood or chocolate-colored fluid 
in the vomitus ; more rarely he has observed that the 
stools are tany. These " spells " have come and gone 
for years. They have been relieved by dieting and by 
drugs ; they have recurred, at longer or shorter inter- 
vals; sometimes there is complete relief from discom- 
fort in the interim, sometimes there is a constant sense 
of dull epigastric distress, necessitating careful dieting, 
often leading to abandonment of hard work, and even 
compelling a semi-invalid life. 



72 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

The family physician watches and tends these cases 
at intervals for years ; he regulates the diet, he pre- 
scribes antacids, anti-fermentatives, stomachics, saline 
and other laxatives, as the case may seem to demand. 
At times he practises lavage with benefit, and finally he 
sends the patient to the specialist or the general hospi- 
tal, with the message that he has tried everything and 
nothing does any permanent good. 

Perhaps by this time the sufferer has entered upon 
the later stage, dilatation, with occasionally an asso- 
ciated gastroptosis. If so, a further and more distress- 
ing chain of symptoms is established. The " spells " 
are more frequent or have become constantly present. 
The patient has grown languid, weak, and emaciated. 
He has lost twenty, fifty, or even a hundred pounds in 
weight. He is fretful, irascible, anxious ; and is called 
by the thoughtless a hopeless neurasthenic. He is tor- 
mented by a constant unquenchable thirst. He has 
abandoned almost all solid food, but whatever he eats 
is taken with dread. Two or three hours after his in- 
sufficient and spiritless meals he has a return of pain in 
the pit of the stomach ; and then he vomits, — some- 
times involuntarily, sometimes by his own will. The 
act of vomiting may relieve the pain. Perhaps he 
vomits but once in the twenty-four hours and then 
in the small hours of morning. The vomitus is very 
foul. It may consist of the food recently eaten only, 
but occasionally he recognizes some old friend ingested 
two or three days before. The amount may be enor- 
mous, — from a pint to a gallon even, he will tell you. 
Gradually, after vomiting, the pain and distress abate, 
and the wretched victim subsides into sleep, awaking 



THE STOMACH 73 

next day to begin again the dreary round. He is annoyed, 
too, by an obstinate chronic constipation; the urine is 
passed in small amounts ; he is a martyr to insomnia 
and headache, and life seems scarcely worth the living. 

When you come to examine such a patient, you will 
find often a fairly characteristic condition. He is pale 
and emaciated, though often well developed, with a 
dry skin and anxious expression. The skin of the ab- 
domen is shrivelled and scaly ; the upper part is flabby 
and soft ; while from the navel down there is ballooned 
a full, elastic, uniform protuberance when the patient 
stands. The belly is nearly everywhere tympanitic ; 
place your hands upon it and shake it, and you may 
elicit a distinct splashing sound. You will see often a 
feeble peristaltic movement as the laboring stomach at- 
tempts vainly to empty itself. Says Osier : " Too much 
stress cannot be laid on the importance of inspection. 
. . . Active peristalsis may be seen in the dilated organ, 
the wave passing from left to right. Occasionally anti- 
peristalsis may be seen." 

Let us pause for a moment and consider the problem 
presenting itself to the physician for solution. The de- 
scription just given is the classic description of a patient 
suffering from a dilated stomach, and one need not go 
much farther in the way of investigation in order to 
make an absolute diagnosis of the condition. But hap- 
pily such cases are becoming rarer, as a more enlightened 
treatment has come to pass. And just as the immense 
ovarian tumor, the magnum opus of the pioneers of 
abdominal surgery, is now seldom seen, so the great 
dilated stomach, though still observed, is less common 
than it was. 



74 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

We must not be content to recognize a fully dilated 
stomach ; we must recognize dilatation early if we would 
save our patients from months, if not years, of inva- 
lidism ; and we must restore them to health, or hold 
the disease indefinitely in abeyance. 

As we have indicated, a dilated stomach is a sec- 
ondary and not a primary condition. The condition is 
an abnormally large stomach, in which there is a motor 
insufficiency. The motor insufficiency is the more im- 
portant condition, — it is the first condition; later comes 
the weakening and distention of the gastric walls. This 
is the usual course of events, but there is a notable ex- 
ception, as is to be expected of all things medical. The 
patient may have been a large eater of coarse foods, or a 
consumer of large quantities of liquids — malt or some 
others. In the course of time the stomach has become 
enlarged to accommodate the daily distending ingesta, — 
this is the condition of " megalogastria," — and this large 
stomach may continue indefinitely with good motor suffi- 
ciency. But such a patient, falling on evil days that 
diminish his bodily vigor, so that the walls of his stomach 
no longer act with their wonted force, — finds that the 
food stagnates and ferments, and then quickly we have 
a condition which, when seen, must be recognized as 
none other than one of gastric dilatation. 

The special point to be remembered is, that there 
may be found in the course of examination a mighty 
stomach, without motor insufficiency, and that this is 
not what is known technically as a dilated stomach. 

Motor insufficiency may be of two kinds : there may 
be weakened power in the stomach muscles to contract 
and force the food along, so that from sheer loss of 



THE STOMACH 75 

muscular tone the food is allowed to stand and stag- 
nate ; or there may be an excess of power developed 
in the muscular wall of the stomach, — but even 
this hypertrophy is not able to overcome the obstacle 
which has developed at the pylorus, and so the food 
stays and ferments, with a gradually resulting dilata- 
tion. 

Thus, we have dilatation in the one case following loss 
of motor power in the stomach, and this brought about 
by weakening of the stomach walls, or an atonic condi- 
tion ; and in the other case by a mechanical obstruction 
to the outgo of food from the stomach. Such an ob- 
struction may be due to the cicatricial contractions due 
to ulcer at the pylorus or in the duodenum, to pressure 
or to inflammatory bands on the outside, to cancer, and 
possibly to kinks at the pylorus, — due to prolapse of 
the stomach (gastroptosis), while in children there may 
be a congenital stenosis. Of the mechanical conditions 
causing dilatation, many demand surgical treatment and 
will be benefited ; others had best be let alone ; but the 
discussion of these propositions will be taken up in 
detail in other chapters. 

How shall the diagnosis of motor insufficiency be 
made early ? By a careful study of each case. Certain 
groups of cases are specially easy to study, for example, 
working-men in whom there is little of the nervous 
element. The fact that they seek treatment is prima 
facie evidence that something definite is the matter. 
In men prolapse of the stomach is rarer than in women, 
and simple atony less common. On the other hand, 
alcoholic gastritis and consequent atony are more com- 
mon in men than in women ; but on the whole, the 



76 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

elimination of nervous phenomena makes the arrival 
at a correct diagnosis more easy. 

Having obtained such information as is possible from 
the history of the patient, and from inspection and pal- 
pation, the next thing to consider is, what can be learned 
from a test breakfast. In such test we must not forget 
that excitement, overwork, and fatigue may enter into 
the problem and cause motor insufficiency, so that we 
may find it advisable to repeat our experiments on dif- 
ferent days to secure control observations. 

If impaired motor function is really suspected, from 
the history, it is legitimate to begin at once by washing 
the stomach early in the morning, when a full meal has 
been taken the night before. By this means one may 
ascertain whether a residuum of any considerable size is 
present. Any remains of food in the morning show 
stasis. The removal of simple, clear fluid without food 
means hypersecretion, and may have nothing to do with 
stasis. In this latter event, one can at the same time 
determine by inflation of the stomach whether it is 
enlarged or not — as well as its position in the abdomen. 

The stomach, having been cleared, is ready for the 
test breakfast, which is removed at the end of an hour. 

Meanwhile the fluid and food removed at the first 
introduction of the tube are examined for lactic acid as 
well as for free hydrochloric acid. 

The test breakfast having been withdrawn, it is 
examined later qualitatively and quantitatively for hydro- 
chloric acid, and a test is made for lactic acid. 

Lactic acid and a normal or increased amount of 
hydrochloric acid are not found in conjunction, hence 
the presence of lactic acid with an absence or very small 



THE STOMACH 77 

amount of hydrochloric acid points distinctly to atony 
or cancer as the cause of the stasis. On the other hand, 
a well-marked hydrochloric acid contents, with fermen- 
tation, points to ulcer as the probable exciting cause of 
the stasis. 

In case stasis has not been suspected, and the test 
breakfast being given and withdrawn, a greater amount 
of stomach contents is expressed than was given, stasis 
must be assumed. In such case, of course, the quanti- 
tative examination for hydrochloric acid is useless for 
comparison ; bat, in so far as it tells whether there is 
much or little hydrochloric acid in a given amount 
of the specimen, it may be an important fact. 

We may suspect stasis, yet find the stomach empty 
when the tube is passed in the morning. In this case 
we shall have to administer a Leube test meal and 
remove what remains, if any, at the end of about seven 
hours. There should be no residue in the normal stom- 
ach after that interval ; therefore, any residue now 
found points to motor insufficiency. The converse of 
this proposition is not constantly true. That is, no 
residue does not assure sufficiency. 

In all cases in which stomach contents has been 
removed, you must let the aspirated contents stand 
long enough to allow an observation of what is taking 
place. When there is marked fermentation, three layers 
quickly appear in the fluid, — at the bottom the solid 
contents, more or less changed by the process of diges- 
tion, above that a clear, watery layer, and on top a 
frothy surface. Through the clear layer bubbles of gas 
are seen to rise and become entangled in the froth of 
the upper layer. With such a picture one is positive 



78 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

that fermentation exists. There are, however, many- 
cases in which partial stasis is suspected, but cannot be 
demonstrated by this crude though practical method of 
observation. 

Another test is to be recommended here, — the fer- 
mentation test. A portion of the Ewald breakfast is 
put into a fermentation tube and the time when fer- 
mentation begins to take place is noted. Riegel states 
that this procedure has been a routine practice in his 
clinic for some time, and that thus a good deal of light 
has been thrown on many cases coming under his obser- 
vation. Hewes has recently developed the technique, 
and has endeavored to find the limits of the onset of 
fermentation in presumably healthy stomachs, so that 
we may have data with which to compare the results 
observed in pathological conditions. A gain is made 
by the fermentation test because small amounts of 
retained and fermenting food may escape the stomach 
tube. Such retained food may cause symptoms, and 
if found, disclose the presence of stasis in a very early 
stage. These remnants, when added to a test breakfast, 
would, when removed, cause fermentation very much 
earlier than would the contents expressed from a nor- 
mal stomach in which there were no such remnants. 
Such a fermenting contents, with a high percentage of 
hydrochloric acid, points to stasis following ulcer, for in 
many cases hyperchlorosis alone is merely an evidence 
of increased motor activity. A large amount of hydro- 
chloric acid may be found combined with marked fer- 
mentation, but other than lactic acid fermentation. In 
the case of diminished hydrochloric acid no diagnosis 
can be made distinguishing an atonic condition from a 



THE STOMACH 79 

carcinomatous obstruction ; so the differentiation must 
be sought along other lines of investigation. 

The history of many cases seems to make it clear, 
even when there is well-marked mechanical obstruction, 
that a hypertrophy of the stomach wall takes place ; and 
because of the hypertrophy, when the patient is taking 
a well-selected diet, the stomach is able to do such 
good work that he is enabled to lead a very satisfactory 
existence. There come times following improper food, or 
great bodily or mental fatigue, when the stomach's power 
of overcoming the obstruction breaks down ; then symp- 
toms of marked dilatation appear with astonishing 
rapidity. Sometimes this is a temporary breakdown 
only, yielding to treatment, but at other times it 
remains permanent. As in the case of broken com- 
pensation in valvular disease of the heart, one attack 
of acute dilatation may become compensated, but is, 
nevertheless, apt to be followed sooner or later by 
others. 

If all the symptoms point to a mechanical obstruction 
of benign origin, the question of operative interference 
must be regarded as a possibility sooner or later. 

As to that consideration, much depends at first 
upon the patient and his position in life — his ability 
and willingness to follow a careful diet and restricted 
work. The patient who cannot have proper care and 
food should be advised to have an operation performed 
and should be encouraged with the idea of receiving 
marked relief from all his sufferings. 

In general the medical treatment of such cases con- 
sists in rest, in small amounts of easily digested food 
with little water taken at the meals, and in proper 



80 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

lavage to secure physiological rest of the stomach and 
to induce a return of tone to the dilated walls. 

In atonic conditions the treatment is wholly medi- 
cal, excepting in those cases in which it seems neces- 
sary through operation to convert for the time being the 
stomach into a mere passage, so that the walls may 
regain their tone as far as possible. In many cases of 
gastrectasis the improvement under medical treatment, 
even when there is well-marked mechanical stasis, is 
remarkable. Under rest, diet, lavage, together with 
laxatives and tonics, the stomach regains its tone, the 
sense of weight and discomfort disappears, eructations 
cease, the bowels empty themselves, pain and vomiting 
are no longer experienced, weight is gained, and vigor 
returns. Even in those extreme cases in which the 
patients have been vomiting quarts at a time every few 
days, improvement may be extraordinary. The patient 
is frequently deceived and leaves the hospital or the 
care of his physician, thinking himself absolutely cured, 
and only too often we hear of him no more. 

What, then, is his fate ? Does he remain comfortable, 
or do the symptoms return ? and even under intelligent 
care, what is the outcome of it all ? 

The writers have attempted to find an answer to 
these questions and in the following fashion : There 
are collected in the clinical index at the Massachusetts 
General Hospital one hundred and seventeen ancient 
cases tabulated as " Gastric Dilatation." The cases of 
recognized pyloric obstruction and dilatation from ulcer 
and cancer and other obvious causes are not in this list. 
It contains those cases only in which gastrectasis existed 
without ascertainable cause. In this list, too, atony was 



THE STOMACH 81 

frequently assumed to be present by the clinician. 
Other causes of dilatation were suspected, but in the 
absence of more definite signs no further positive diag- 
nosis was made, and the cases, with very few exceptions, 
were treated " medically," as the phrase is. Let us 
then, for the sake of our own better information, make 
some study of these cases, of their treatment and out- 
come, which we have followed up so far as it was pos- 
sible for us so to do, and see how far the results bear 
out our statements already made. 



CHAPTER IV 

THE STOMACH (Continued) 
DILATATION TREATED WITHOUT OPERATION 

We purpose in this chapter to tell of sixty cases of 
gastrectasis treated in the medical wards of the Massa- 
chusetts General Hospital in the years 1888-1903, and 
of the end-results which it has been possible to obtain. 
In the list those cases are not included in which definite 
diagnoses of organic disease were made. Such cases will 
be considered in their appropriate chapters. 

The cases described here were of chronic dyspeptics 
who had suffered anywhere from a year to a lifetime 
and were admitted to the hospital wards for treatment. 
They are listed in the hospital under " Dilatation of 
the Stomach," because no more accurate diagnoses were 
made. Why, in the light of subsequent investigations, 
some of these cases were not more carefully analyzed it 
is hard to see. 

There are recognized by clinicians a male and a female 
type of dilatation ; the male type is more likely to be a 
great lateral dilatation, discovered by tympany above 
the umbilicus, extending beneath the ribs upon the left 
and pushing up the diaphragm. This type is frequently 
seen among alcoholics in dispensary practice, and is usu- 
ally treated successfully in out-patient departments. It 
is not to this alcoholic type that we refer ; indeed, of 

82 



THE STOMACH 83 

the forty-one male cases to be described, six only could 
in any sense be called alcoholics. 

The female type of dilatation is the long stomach dis- 
tended toward the pubes, usually associated with gas- 
troptosis, though a prolapsed stomach is not necessarily 
always dilated. We used to regard many of these cases 
as atonic, and doubtless many of them are so ; but, in 
the experience of the Massachusetts General Hospital, 
the majority of atonic cases, if curable or susceptible of 
relief, find their benefit in the out-patient department 
and are not met with in the hospital wards. 

There were listed in the index catalogue of the hos- 
pital, in the last fifteen years, one hundred and seventeen 
cases of " Dilatation of the Stomach." We have traced 
sixty of those cases, a little more than 50 per cent ; of 
the fifty-seven untraced cases it is probable that many 
are dead. Certainly dead men are less easily discovered 
than the living. 

A passing word about those fifty -seven lost cases. 
We have a record of their condition when they left the 
hospital : one was " well " ; sixteen were " much im- 
proved " ; twenty -seven were " improved " ; eight were 
" slightly improved " ; five were " not improved." 

Of these fifty -seven cases, forty-two were males and 
fifteen were females. The average age of the males was 
46.5 years, the average age of the females 42.6 years ; 
not that there is any special interest or significance 
in these figures, except that they will be found to 
correspond later with those of the patients who have 
been traced. 

The records show that when those cases which could 
be traced left the hospital, two were well, two unim- 



84 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

proved, and forty-seven improved ; nine died in the 
hospital. At the time of our investigation the report is 
as follows : — 

In sixty cases traced ; end-results : well, seven ; unim- 
proved, nineteen ; improved, five ; dead, twenty-nine. 

This is not an encouraging showing ; let us consider, 
however, some of the facts and figures in detail, and 
learn what we may of this interesting but unclassified 
group. 

In the first place, it is striking that of the sixty cases, 
forty-one were male and nineteen were female • while at 
the same time the hospital records show that during 
that period of fifteen years the total female entries of 
all classes of cases somewhat exceeded the male entries. 
The explanation for the reversal of figures in the cases 
under consideration probably lies in the fact that the 
majority of women with stomach disease who entered 
the hospital were found to have clear histories of gastric 
ulcer, and were listed under that heading. 

The ages of the men varied greatly ; the youngest was 
twenty-seven, the eldest was sixty-four, and the average 
age was forty-seven years. The youngest woman who 
entered was twenty-two years, the eldest was sixty-nine, 
an average being 40.3. These figures correspond closely 
with those usually given, and when we come to study 
diagnoses it will appear that cancer was less commonly 
seen among the women than among the men when the 
patients were admitted. 

The duration of symptoms in both sexes varied all the 
way from twelve months to forty years. 

As one would expect, the loss of weight varied greatly, 
though the records do not always state the exact figures. 



THE STOMACH 85 

The variation, however, runs from zero up to a loss of 
one hundred pounds, and seems to be of no special value 
in throwing light on a more refined diagnosis. 

Pain was an almost constant symptom in these sixty 
cases ; five only of the patients were without it. It is 
variously described as coming on immediately after eat- 
ing, several hours after eating, relieved by eating to 
return later, and many times as being constantly pres- 
ent. As one would expect, when there was pyloric 
obstruction, late pain was much the most common. It 
is described as a burning, gnawing, throbbing, dull, and 
boring pain; and many persons are found in the class 
who complained of constant pain. In all the cases it 
appears that the pain was relieved by vomiting. 

Vomiting was present in fifty-seven of the sixty cases. 
Two of the cases stated that they vomited in the absence 
of pain, but in no case were both pain and vomiting 
absent. The vomitus varied, of course, in amount ; 
and one reads of belchings, spittings up, vomiting the 
last meal taken, or vomiting enormous amounts typical 
of cases of great dilatation. 

Fifteen, or a quarter of the sixty cases, gave a history 
which might suggest that there had been at some time 
a distinct hemorrhage from the stomach ; only three, 
however, gave a clear history of frequent vomiting of 
blood. One case also passed stools suggestive of gastric 
or duodenal ulcer. A consideration of this one symp- 
tom of hemorrhage alone shows that a considerable 
number of these cases would undoubtedly to-day be 
analyzed further, and put into the group of cases in 
which the dilatation was due either to ulcer or malig- 
nant disease. 



86 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

The analyses of gastric contents as given in the records 
are not satisfactory. Indeed, one would scarcely expect 
satisfactory accounts, from our present point of view, in 
cases running back ten or fifteen years. As we come 
down toward the present date, however, the analyses 
are found more accurate, but apparently no more final 
for the establishment of diagnosis. This criticism of the 
records is equally true of all manner of cases recorded 
in former years, and the fact that in all departments 
of clinical research our present observations are better 
than those former ones indicates merely that we know 
more than we used to know. The signs " splashing " 
and " visible peristalsis " are seldom recorded in the 
early records, although they must have existed. Their 
significance was apparently disregarded or overlooked. 

The treatment of all these cases need not be entered 
into at length; it was what, the physical examination 
and analyses obviously suggested. The patients were 
put to bed, and lavage was employed commonly, being 
used in forty-four out of the sixty cases. Most of 
the individuals were given such tonics as nux vomica, 
capsicum, light wines, strychnine, and iron. In suitable 
cases a full diet was employed, in others a dry nitroge- 
nous diet, and in others still a liquid diet. It is interest- 
ing to note that of all the sixty cases five only were 
given HC1 regularly, and two only were fed upon nutrient 
enemata. 

In all these cases cathartics were employed, — such 
as Carlsbad salts, aloes, strychnine, belladonna, cascara. 

Such, in very brief outline, is a summary of our notes 
upon the sixty cases as a whole. Let us now consider 
in more detail those cases which died or recovered, 



THE STOMACH 87 

and see if in any way such facts as we have are 
significant. 

Seven cases recovered, and after several years report 
themselves as well ; two of them are women, five are 
men. The first and most striking thing about all these 
is that the recoveries took place in persons in middle 
life who had been many years dyspeptics, — their 
periods of invalidism running from five to forty years 
individually, an important fact for the consideration 
of those enthusiasts who are urging immediate operation 
on all cases of chronic dyspepsia. 

The dead: of the sixty cases, twenty-nine (48.3 per 
cent) are reported dead, and the causes of this large 
number of deaths are the subject of serious impor- 
tance in this inquiry. We are constantly being told, 
and with reason, that the greatest danger of long-con- 
tinued stomach disease, after early life, is cancer, — the 
probability of malignant disease developing on the site 
of ulcer. After careful inquiry, it appears that in 
fifteen, or over 50 per cent, of these twenty-nine deaths, 
cancer was assigned as the cause of death. Our figures 
are suggestive either way, but prove nothing either way. 
Of the fifteen deaths from cancer, six followed a history 
of many years' invalidism. These six patients had had 
stomach symptoms for five, seven, nine, ten, twelve, 
twenty, and " many " years ; they sought relief at the 
hospital as a last resort, and most of them died a few 
months after their entrance. The probability, of course, 
is that the above-stated contention is sound, and that 
in these cases cancer had been implanted upon long- 
standing non-malignant disease. 

In the remaining nine cases of death from cancer, 



88 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

the disease ran a short course from the initial symptoms 
to the end, the average duration being seventeen 
months. The shortest case is recorded as four months 
in all, and the longest as thirty-nine months. These 
figures dealing with the duration of cancer correspond 
fairly well with those of von Mikulicz, Moynihan, and 
other writers. 

The causes of death in the remaining fourteen per- 
sons, of whom cancer is not reported, are " starva- 
tion " ; although for a certain proportion one suspects 
cancer, the presence of which was not disproved, from 
lack of autopsy. 

For the cancer cases one final note is interesting; 
namely, that with two exceptions all died within nine 
months after leaving the hospital, no matter what the 
duration of the disease may have been before entrance. 
The two exceptions must have developed their cancers 
after they left the hospital, for their deaths are re- 
corded in three years and five years subsequent to the 
date of hospital discharge. 

Of the fourteen cases against whom the diagnosis of 
cancer cannot be written, eleven died within a year 
after leaving the hospital. Lack of proper returns and 
autopsy records leaves us without definite conclusions 
in regard to these cases, but we must assume that with 
many of them cancer was the cause of death. Eleven 
of these cases were of short duration after their dis- 
charge and had been ill previously for periods varying 
from four months to twenty-three years. 

Three of the non-malignant cases lived six, five, and 
six years after their discharge, and died eventually of 
" stomach trouble." 



THE STOMACH 89 

To put our facts in other words : of the twenty-nine 
fatal cases, twenty were short cases, ill but a few months 
before entering the hospital and dead a few months 
after leaving. Nine were long cases ; and of the long 
cases four died of cancer soon after coming under ob- 
servation ; two died of cancer several years after being 
studied at the Hospital ; and three died of wasting 
gastric disease other than cancer. 

The figures may be juggled in many another inter- 
esting fashion, but nothing is proved beyond the first 
obvious fact, that nearly 50 per cent of these cases of 
gastrectasis died, and that about half the deaths were 
due to cancer. These cases speak eloquently as to the 
difficulties to be encountered of making a full and 
accurate diagnosis even in hospital work. 

Nineteen of our cases have been found worse or 
imimproved since leaving the hospital, and many of 
them are so seriously ill that we must expect them 
shortly to be ranked with the dead ; eleven of them are 
men and nine of them are women. Their ages are 
unimportant, but we may note that they averaged at 
entrance forty-three years, the youngest being a man 
of twenty-eight, and the eldest a man of sixty-four. 
And the duration of their invalidism varies all the 
way from one year to twenty-eight years, the average 
being 10.7 years. Most of them, however, give histories 
of long-continued dyspepsia, either before entering or 
since leaving the hospital, so that it is fair to state 
that in very few, if any, of these cases are we at 
present dealing with malignant disease. The essential 
symptoms have been epigastric pain after eating, which 
is present in all of the nineteen, and occasional vomit- 



90 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

ing, which is present in seventeen of the nineteen. The 
symptom of ancient hemorrhage has been present in 
but six of the cases, and such hemorrhages were so 
long ago recorded that a positive diagnosis of gastric 
ulcer cannot very well be made. The presence or 
absence of HC1 in these cases is interesting. It was 
present in sixteen of the cases and persistently absent 
in three ; yet those three cases obviously had no cancer, 
for they have continued living on feebly for nine and 
ten years since leaving the hospital, — indeed, one of 
them has been an invalid fifteen years, the second 
thirty-three years, and the third thirty-four years. In 
all of the nineteen unimproved cases there was greatly 
delayed motility with a gastric capacity considerably 
increased. They have gone on living many years since 
leaving the hospital, but all are hopeless invalids, de- 
pendent on others for their support. It is a depress- 
ing series of biographies. 

Five cases of our sixty are reported as " improved" 
Though not to be placed in the class " well," they 
approximate that class, and may be considered in the 
same connection. Two are females and three are 
males, and their ages vary widely, the youngest being 
a woman of twenty-two, the eldest being a woman of 
fifty-four, at entrance. 

Taking these five cases in some detail, we note : — 
Case 1. Was fifty-four years old at her entrance, 
fifteen years ago, and is now fairly comfortable at the 
age of sixty-nine. She had been ill twenty-one years 
when first seen at the hospital, so that now, in her old 
age, she has been a dyspeptic for thirty-six years. Her 
symptoms have been occasional epigastric pain after 



THE STOMACH 91 

eating, and occasional vomiting. It is recorded that 
some twenty years ago she vomited blood twice, and 
the presumption is that she has a slight pyloric ob- 
struction due to a healed ulcer. At the Hospital the 
stomach contents contained free HC1. She w^as 
treated by lavage, cathartics, tonics, and nutrient enem- 
ata, and be it noted that this case and the next are 
the only ones in our list of sixty of whom it is recorded 
that they were treated by nutrient enemata. This 
patient continues the use of the stomach tube at home 
and enjoys a fairly comfortable existence, — a good 
example of what may be expected in moderate stenosis 
of the pylorus under fairly favorable circumstances. 

Case 2. Was a man thirty-nine years old who had 
been acutely dyspeptic for one year. He too had had 
and has epigastric pain, occasional vomiting, and has a 
record of one hemorrhage about nine years ago, before 
entrance, and he too doubtless has a slight pyloric 
obstruction due to a healed ulcer. No free HC1 was 
found present ; there was abdominal splashing, and he 
was treated by lavage, was given HC1, and fed by nutri- 
ent enemata. He reports himself as fairly comfortable. 

Case 3. Was a young woman of twenty-two who had 
been a dyspeptic for eighteen months, with epigastric 
pain several hours after eating and occasional attacks of 
vomiting. At one time, shortly before entrance, she 
vomited blood ; HC1 was present ; she was treated by 
lavage, was discharged after two weeks, and reports her- 
self as fairly comfortable so long as she uses the stomach 
tube. 

Case 4. Was a man of thirty-nine who had had symp- 
toms for twelve years. Now, fourteen years since his 



92 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

discharge, he looks back on twenty-six years of dyspepsia. 
He is thin, — twenty pounds below his normal, — with 
occasional attacks of pain and vomiting ; HC1 was 
present in his case ; he was treated and continues to 
treat himself by lavage. 

Case 5. A man of fifty-two at entrance, had symp- 
toms of comparatively short duration, — three years 
before entrance and two years since. He has lost 
thirty pounds in weight and has the usual symptoms 
of occasional pain after eating and occasional vomit- 
ing ; HC1 was present in his case ; and he continues 
fairly comfortable with the use of lavage. 

All of the above Hive cases had dilatation of moderate 
extent with a gastric capacity ranging from forty to 
eighty ounces, and delayed motility ; indeed, except for 
the disparity in age, they seem quite similar. 

The lesson, apparently, to be drawn from this is that 
patients with mild degrees of dyspepsia, in whom there 
are healed ulcers with some pyloric obstruction, may be 
kept fairly comfortable by the continued use of lavage, 
which prevents accumulations and consequent fermen- 
tation, but cannot be made completely well while the 
obstruction, mechanical or functional, with its conse- 
quent dilatation and malnutrition, persists. However, we 
must not forget that such an existence to many persons 
is preferable to the thought of undergoing an operation. 

The well : As with the class of " improved," the 
" well " occupy but a small space in our list. Seven 
persons out of sixty report themselves well. When we 
come to study the figures we find little that is signifi- 
cant. The ages of the patients on entrance varied from 
twenty-nine to fifty-seven ; five of them were men, two 



THE STOMACH 93 

were women ; and while the two women had been ill 
twenty and fifteen years respectively, the men had been 
ill for from six months to forty years ; in no case was 
there a striking loss of weight, except in that of a man 
of forty-two who had lost forty pounds. In brief detail 
the records are as follows: — 

Case 1. Was a man of fifty-seven, who had been ill 
forty years and lost five pounds; he was a carpenter 
and there was some suspicion of lead colic about him ; 
during this long period he had had frequent attacks of 
gnawing epigastric pain relieved by food ; sometimes 
vomiting would relieve the pain, and he had vomited 
as much as two quarts at a time ; he was constipated 
and flatulent ; he was thin and neurotic. The lower 
border of his stomach was four inches below the umbili- 
cus, there was a residue of eight ounces, thin undigested 
food, not foul ; there was abundance of free HC1 and 
no lactic acid. The man was put on a dry nitrogenous 
diet with bicarbonate of soda, iron, and gentian ; after 
six weeks he was discharged well. For the past nine 
years he has remained well. 

Case 2. Was that of a man very different from the 
last ; he was thirty-five years old and had had symptoms 
for three years only. At the hospital they thought he 
might have cancer, but that was eleven years ago and he 
is still living. For three years he had debility, poor 
appetite, and epigastric pain coming on half an hour 
after food. He was an emaciated man, and there was 
abdominal splashing. At the hospital they fed him up 
and gave him HC1. His stomach was dilated to the 
umbilicus. In two weeks he went home "well." He 
has been well ever since. 



94 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Case 3. Was a good deal more serious ; it was that 
of a man forty-two years old, whose stomach reached 
three inches below the umbilicus, with a capacity of sixty 
ounces ; HC1 was present and no lactic acid. For many 
years he had had occasional vomiting of about fifty ounces 
at a time. He had lost forty pounds. At the hospital 
they washed him out and fed him up, and at the end of 
two weeks he went home, taking with him a stomach 
tube, since unused. That was six years ago, and he has 
been well ever since. 

Case 4. Was that of an emaciated middle-aged man, 
who had been vomiting occasionally for ten years, and 
usually at midnight ; he used quite frequently to have 
pain after food, there was some ptosis of the stomach, 
and the dilatation extended four inches below the umbili- 
cus. A residuum of five ounces was expressed and much 
free HC1 was present, as well as butyric and lactic acids. 

It is evident, from the tone of the record, that this 
was regarded as a rather ugly case ; but they gave him 
Carlsbad salts, washed his stomach out, sent him home 
with a tube, and he has been well ever since. That was 
four years ago. 

Case 5. Also looked unpromising ; it was that of a 
man forty-four years old, who had epigastric burning 
and dull aching two or three hours after food for many 
years. He had lost twelve pounds. The pain was 
evidently relieved by food, but came on again later, and 
often he used to vomit up a pint or more. He had 
ptosis of the stomach, too, and splashing, with the greater 
curvature two inches below the umbilicus. His gastric 
capacity was fifty-three ounces, and free HC1 was 
present. 



THE STOMACH 95 

They gave him a milk diet, salts, bismuth, and bicar- 
bonate of soda, with daily lavage. He went home well, 
and is well to-day after four years. 

Case 6. Was that of a young woman twenty-nine years 
old, who had been a dyspeptic for twenty years, and 
had vomited mucus and food at varying intervals dur- 
ing that period. There had never been any significant 
pain, but she was emaciated, with a stomach four inches 
below the umbilicus ; without HC1 and with lactic acid 
present. 

She was put on a full diet, after three days of which 
HC1 was found. After three days of such treatment, 
and with lavage, she left the hospital with a stomach 
tube and slightly relieved. 

Here is a quotation from her letter written twelve 
years after leaving the Hospital. It is instructive and 
somewhat entertaining. " All of the symptoms re- 
turned after leaving the hospital, and for three or four 
years I was very ill indeed and finally was persuaded to 

go to Dr. F ; after treating me for about ten months, 

he succeeded in curing me almost entirely. I gained in 
that time about twenty pounds and have gained almost 
steadily since [sic, for eight years !]. 

" Dr. F does not believe in washing the stomach. 

I am sure that the thing which did me the most good 
was teaching me how to live. I can now eat almost 
anything and, unless I am indiscreet, rarely have return 
of the old trouble." 

Case 7. Was that of a widow of thirty-eight, with a 
history of fifteen years of dyspepsia. The record notes 
the fact that she was a neurasthenic with a slightly 
dilated stomach. During these fifteen years she had 



96 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

had occasional attacks of vomiting, but no haemateme- 
sis ; she was constipated, thin, and excitable ; she spent 
three weeks in the hospital being fed up, and being 
given tonics. Then she was discharged " relieved." A 
month later she reentered the hospital, to stay there two 
months under the same treatment, and was then dis- 
charged well. She had no gastric lavage. 

Eleven years have elapsed and she reports herself in 
excellent health. 

Of these seven persons who recovered and have re- 
mained well there is nothing especially in the history to 
distinguish them from the persons who died or the 
persons who continue dyspeptics. All appeared unfa- 
vorable cases for treatment ; none of the seven had 
hemorrhages ; six had vomiting, and in every case 
there was either vomiting or pain or both ; each one 
had a dilated stomach. They are shining examples of 
what may be done " medically " with unpromising cases. 

In this "well " class, again, the investigation of gastric 
contents determined nothing except that delayed motil- 
ity was shown ; four cases had HC1, three of them had 
it not ; two of the cases showed lactic acid, and five of 
them showed none ; four of the cases, those with most 
dilatation, were treated by lavage ; three of them, those 
with slight dilatation and of the neurasthenic type, 
were not so treated. All of the cases were in middle 
age or just about entering upon that period of life ; and 
all of them are living still, well advanced in middle age 
or old age. 

Just what may be the causes of dilatation in these 
" well " cases is not apparent, but certain it is that they 
have been fortunate enough to pass through long periods 



THE STOMACH 97 

of gastric disease without developing cancer and that 
they are now well, — these seven out of sixty. 

In resume we may say, as we have already stated, 
that we have been considering a series of cases in 
which the diagnosis was made of a prominent symptom 
which has several important etiological causes. For 
one reason or other, best known to the clinicians under 
whose eyes these cases came during the past fifteen 
years, no success was attained in separating these 
cases into their etiological groups for diagnostic pur- 
poses. This is not surprising when we remember the 
general disfavor with which dyspeptics have been 
treated in years past — they have received scant atten- 
tion in too many instances. In the light of our present 
knowledge and with the present enthusiasm for stomach 
work, it seems more than probable that this diagnosis — 
gastrectasis — would not be the only one made to-day 
in many of our cases. The series shows distinctly that 
a goodly number would be regarded as cases of mechani- 
cal obstruction, probably of benign origin. The difficul- 
ties in the way of diagnosis are illustrated by the resulting 
cures in some of the most unfavorable cases, and in the 
rapidly following deaths in others presenting the mildest 
symptoms, as well as symptoms of the shortest dura- 
tion. It must, however, be held firmly in mind that 
while many of our present diagnostic procedures have 
been known for years past, their complete application 
in a practical logical manner has been a matter of a few 
years' standing only. The surgeon who is given to 
criticising medical diagnosis and treatment should re- 
member also that he must be as lenient in his judgment 
of past medical diagnosis and treatment as he wishes 

H, 



98 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

internists to be when he asks them to blot out from 
their remembrance the statistics of all gastric surgery 
done before the year 1904. Certainly a number of the 
above cases of dilatation would apparently have been 
benefited by an operation for the relief of the mechani- 
cal obstructions which evidently gave rise to the symp- 
toms ; and the point to be insisted upon is that, after all 
possible attempts have been made to reach a clear un- 
derstanding of the causes of gastrectasis, and after the 
adoption of suitable " medical " measures without bene- 
ficial results, then operative measures are to be considered 
and a surgical consultation called. 



CHAPTER V 

ULCER OF THE STOMACH AND DUODEXUM 

It is fair to state that of all lesions giving rise to 
digestive disorders, ulcer of the stomach and duodenum 
holds the first place. Probable as this proposition is, 
however, it seems impossible of demonstration; and by 
ulcer we mean ulcer and its sequelae. There are vari- 
ous reasons for believing in the really conspicuous posi- 
tion of ulcer, and as surgical treatment of gastric lesions 
is opening to us more frequent opportunities of making 
inspections during life, surgeons are coming to feel that 
the old-time statistics of the frequency of ulcer are 
incorrect. 

The commonly quoted figures among us on the sub- 
ject are those of W. H. Welch, 1 who estimated that 
about 5 per cent of mankind suffer from gastric ulcer, 
and those figures were founded on the findings at autopsy 
of open or cicatrized ulcers. 2 Other writers have placed 

1 Pepper's " System of Medicine," 1885, Vol. II, p. 482. 

2 " Ulcer of the Stomach," by Franz Riegel, Xothnagel's " Encyclo- 
pedia of Practical Medicine," ed. 1903, p. 548 : " The best way of 
estimating the frequency of gastric ulcer is to study autopsy statistics. 
According to Berthold, 262 cases of ulcer were found in the Pathologic 
Institute of the Berlin Charite in the fifteen years from 186S to 1882; 
this means that ulcer or evidence of old ulcers was present in 2.7 per 
cent of all the cases that were examined post mortem in that Institute ; 
of these cases 128 occurred in men and 134 in women. 

" The figures obtained in the Munich Pathologic Institute are not so 
high. According to Xolte, ulcer was found in only 1.23 per cent of all 

lofc. 09 



100 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

the percentage very much lower, as Lebert, who made 
it 0.64 per cent. Then there are the familiar tables col- 
lected by Greenough and Joslin, 1 showing that at the 
Massachusetts General Hospital in Boston the percent- 
age was 1.043 ; at the Johns Hopkins Hospital, Balti- 
more, 0.32 ; at the Cook County Hospital, Chicago, 0.15, 
and at the Arapahoe County Hospital, Denver, 0.12. 
Writers go on to show that geography has a great deal 
to do with the matter, and Welch's records are usually 
the final ones named in this connection : 2.7 per cent 

autopsies; of these 0.8 per cent were seen in men and 1.8 per cent in 
women. Griess, in Kiel, found ulcer in 8.3 per cent; Ziemssen, in 
Erlangen, in 4.55 per cent; Stoll, in Zurich, in 2.16 per cent; Stark, 
in Copenhagen, in as many as 13 per cent. Brinton states that 5 out of 
every 100 autopsies revealed the presence of gastric ulcer. Griinfeld 
found exceptionally high figures; he succeeded in demonstrating the 
presence of ulcer scars in 92 out of 450 autopsies (241 women and 209 
men) — that is, in 20 per cent ; of the 92 cases, 77 were found in women 
and 15 in men. 

" Fiedler examined 2200 bodies, and found ulcers or cicatrices in 20 per 
cent of female bodies, and in 1.5 per cent of male bodies. The attempt 
has been made to explain these variations as due to certain regional dif- 
ferences ; in part, however, they must be attributed to the different clinical 
material that enters different hospitals ; I have called attention to this 
point in another place when discussing mortality statistics." 

The Pathological Records of the Boston City Hospital, quoted by Sears, 
show that of 2127 autopsies done at that institution since 1896 there are 
but 29 ulcers of the stomach and duodenum recorded (1.3 per cent) . 

Howard reports that the clinical observations in all services at the 
Johns Hopkins Hospital in a period of fifteen years, 44,000 cases, show 
that ulcer of the stomach was recognized but 87 times (1 in 506 cases) . 

At the Massachusetts General Hospital, since the opening of the new 
Out-patient Department, August 31, 1903, to March 22, 1905, 41,385 new 
patients were treated, and 10,845 of these were medical cases. The diag- 
nosis ulcer of the stomach has been made but 54 times, and in this list 
are a number of cases in which the diagnosis of cancer was probable, as 
well as of old stenosis cases, and some of doubtful diagnosis. 

1 American Journal of Medical Sciences, August, 1899. 



ULCER OF THE STOMACH AND DUODENUM 101 

for Berlin, 1.23 per cent for Munich, 8.3 per cent for 
Kiel, 10 per cent for Jena, and 13 per cent for Copen- 
hagen. Interesting as all these figures are, and great as 
is the diversity of conclusions drawn, it seems fair to 
state that the medical and autopsy records alone show 
5 per cent of all men to suffer from gastric ulcer, and 
at the same time it is not unwarrantable to assert that 
the true percentage is probably higher. 1 

Such being the case, it is interesting to inquire under 
what conditions of symptomatology shall we conclude 
the presence of gastric ulcer. Those sixty cases of gas- 
trectasis studied in Chapter IV suggest strongly that 
ulcer is or has been present in great numbers of cases 
in which diagnoses could not definitely be made. 2 

The presence of a gastric ulcer does not mean neces- 
sarily pain and bloody vomiting, nor must we think of 
ulcers as being always of the same type. Here is a case 
in point. 

A lady of forty-five consulted us some months ago, 
saying that she had had chronic dyspepsia for twenty 
years. For most of that time she bore it without much 
complaint and had not materially lost vigor, though she 
never felt very well ; she used to have a little pain in 

1 M. C. Millet (St. Paul Medical Journal, 1903) observes, "If we take 
even the lowest percentage as found post mortem, viz. 1.50 per cent, we 
see that every other case is undiagnosed in life." 

2 "Latent ulcers are not uncommon; Savariaud gives their proportion 
as 20 per cent of all cases of gastric ulcer ; ... it is difficult to explain 
why some of these ulcers should exist without producing symptoms. . . . 
In the cases we have seen, the ulcer has been near the lesser curvature of 
the stomach, and this might possibly afford an explanation, since in this 
situation they would be brought less intimately into contact with food." 
" Surgical Treatment of Diseases of the Stomach," by Mayo Robson and 
Moynihan, 1901, p. 104. 



102 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

the epigastrium whenever she ate solid food. She tried 
dieting in various ways without special benefit ; she 
was never nauseated, and the pain usually subsided 
after two hours. She had gone the usual round of 
physicians, but had grown discouraged, and for the 
last four years had done the best she could for herself. 
In the past year her symptoms had become decidedly 
worse; all food, and even water, caused pain immedi- 
ately it was taken ; the pain was in the same old place 
and often radiated to the back and left shoulder blade ; 
she had become afraid of food and had grown melan- 
choly and almost suicidal. 

All this was bad enough, and we must remember that 
it came after many years of increasing ill health, during 
which time she had been content to go about ranked 
among those whom we rather flippantly call chronic dys- 
peptics. Further details of the case are needless here, 
except to tell the result. The abdomen was opened, 
and there was found a broad cicatrix furrowing the 
anterior wall of the stomach ; it was undoubtedly the 
result of long-standing ulcer, now healed, and the hour- 
glass constriction which it caused had the immediate 
effect of producing the distressing symptoms. The 
patient has been well since an operation for giving 
proper stomach drainage. We must conclude that the 
constant symptoms running over years should have sug- 
gested some anatomical lesion, and an operation should 
have been done long ago. 

Such facts as the above are perfectly well known, but 
they are not perfectly well appreciated. Osier puts the 
familiar experience thus : 1 " The condition [ulcer] may be 
1 Osier, " Practice of Medicine," p. 481. 



ULCER OF THE STOMACH AND DUODENUM 103 

met with accidentally, post mortem. The first symptoms 
may be those of perforation. In other cases, again, for 
months and years, the patient has had dyspepsia and 
the ulcer may not have been suspected until the occur- 
rence of a sudden hemorrhage." 

So persistent dyspepsia is our leading feature, while 
we must bear in mind always that, even without dys- 
pepsia, ulcer may exist. 

The other symptoms are well recognized, and, when 
present, they suggest to any tyro the diagnosis. Vom- 
iting and pain are the symptoms most conspicuous ; 
disturbances of secretion and motility are the important 
facts upon which to establish our conclusions. 

It seems needless here to consider at length the 
symptomology of ulcer, but a few words quoted from 
the excellent monograph of Greenough and Joslin may 
show briefly the importance and significance of symp- 
toms, so far as they may be shown in the study of a 
few cases : — 

" The order of frequency of the chief symptoms oc- 
curring in the hospital patients was as follows : — 

Frequency of Symptoms Total Number of Patients, 18T 

Vomiting 179 cases, or 95.7 per cent 

Pain 173 cases, or 92.5 per cent 

Vomiting of blood .... 147 cases, or 78.6 per cent 

Pallor 131 cases, or 70.1 per cent 

Tenderness 130 cases, or 69.5 per cent 

Constipation 123 cases, or 65.8 per cent " 

What these writers say in regard to the time of 
vomiting is extremely interesting and corresponds 
closely with later investigations. « Vomiting was the 
symptom most uniformly present, being absent in but 



104 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

four patients, and with the matter left doubtful in four 
others. 1 The time of vomiting was so variable in the 
different patients, and in fact in the same individual, 
that little of value could be gleaned from the records 
in this regard. This is unfortunate because the state- 
ments of authors diverge so widely on this point. 
Ewald and Leube say the vomiting occurs soon after 
eating. Boas puts it at the height of the paroxysm of 
pain, and Osier < not for two or more hours after eating.' 
Hemmeter does not commit himself. Thus these con- 
flicting statements show that the time of vomiting is 
not a factor in diagnosis. The quantity of the vomitus 
is also indefinite, for one must take statements of the 
amount of vomitus with caution." These questions of 
the time and amount of vomiting are of much negative 
interest, for in the experience of the writers, as of that 
of the authors just quoted, there is no rule ; so that for 
diagnostic purposes the mere fact of vomiting, and 
sometimes its quality alone are of value. 

The presence, location, and character of pain also 
vary greatly ; though in the majority of cases pain is 
present, — most commonly in the epigastrium and also 
in the back not infrequently. Pain referred to other 
regions, such as the hypochondrium or the shoulders, is * 
not nearly so frequent. Of the one hundred and eighty- 
seven patients studied by Greenough and Joslin, four- 
teen had no pain. Our own study of cases shows us 
that tenderness has no regular relation to pain, an ob- 
servation contrary to that of Osier and Leube ; while 

1 This is the more interesting in view of our appreciation of the 
fact that many cases of gastric ulcer run their course without vomit- 
ing. 



ULCER OF THE STOMACH AND DUODENUM 105 

Fitz says that press are sometimes aggravates and at 
other times lessens pain. 

It appears to be more difficult, with our increasing 
knowledge of gastric ulcer, to estimate just how often 
hemorrhage is present in that condition ; but it is very 
certain that it may be absent from a large group of 
cases. The estimated percentages vary all the way 
from 46 x to 81. 2 Hemorrhage appears to bear no special 
relation to age or sex, to duration of the ulcer, or often 
even to food ; so that for diagnostic purposes we must 
regard it merely as one of a symptom-complex. 

Writers discuss sundry other symptoms, such as 
pallor, which, after all, when investigated shows us only 
that the blood is that of a chlorotic type of anaemia; 
and constipation, which must properly be regarded as 
a symptom of no diagnostic value. 

All of these questions must be considered further 
in detail. 

To one reading the literature of gastric ulcer, quickly 
it becomes apparent that too little regard is paid in the 
discussion to the various types of ulcer ; yet the type 
in a great proportion of cases is of the utmost impor- 
tance when we come to consider treatment. For our 
purposes we may discuss three types, erosions, acute 
round ulcer, chronic ulcer ; and surgically the third form 
is far the most important. 

Let us omit, from the present consideration, syphi- 
litic, tubercular, and malignant ulcers, and study those 
forms described as simple ulcers by Cruveilhier, as well 
as the erosions of Dieulafoy. 

The erosions are " simple," mere bleeding abrasions 

1 Leube. 2 Greenough and Joslin, 



106 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

of the epithelium, from which, however, alarming venous 
hemorrhage may occur ; and there are the more exten- 
sive erosions which may involve large portions of the 
mucosa of the stomach. 1 These conditions are impos- 
sible of diagnosis during life, except by operative ex- 
ploration ; and the treatment of them, though usually 
consisting of rest and careful dieting, may involve 
gastro-enterostomy for drainage, — to be considered 
later. 

The round ulcers of the acute and chronic form are 
often exceedingly difficult of differentiation, though the 
typical cases are very obvious. As a cause of dyspeptic 
conditions, acute ulcer occupies a place subordinate to 
chronic ulcer, and that this is true we are coming to rec- 
ognize clinically. Acute ulcer attacks the victim sud- 
denly, it tends spontaneously to heal, it may have as 
symptoms hemorrhage and pain, one or both ; but 
there is reason to suppose that often pain is the only 
symptom. Without seeking advice, patients seem to 
find that food increases the pain. They learn to ab- 
stain and to employ a careful diet, so that in a few 
days, often, apparent healing takes place. 

The cases of acute ulcer which do come to the physi- 
cian or the surgeon are of a more alarming type, but 
probably are a minority of all the cases of acute ulcer, 
and this fact every practitioner constantly must bear 
in mind. You are never safe in assuming that no ulcer 
has been present merely because there has been no 
hemorrhage. The commonly accepted symptoms of 
acute ulcer, hemorrhage and pain, are familiar enough. 

1 The clinician should never forget the hemorrhages from the stomach 
due to disease of the liver and kidneys. 



ULCER OF THE STOMACH AND DUODENUM 107 

There may have been a few days of gastric distress or 
there may not, and often the patient's first knowledge 
of trouble is a sudden, profuse, and alarming hemor- 
rhage, or an agonizing pain in the epigastrium. If a 
hemorrhage is all there is to it, the affair will usually 
take care of itself, with rest and fasting. People rarely 
die from these acute-ulcer hemorrhages, and operations 
are not immediately advisable. But pain is a far more 
serious symptom, especially when it is sudden and 
severe. It often means perforation, and is followed by 
collapse, a rising pulse, a rising and then a subnormal 
temperature, exquisite localized tenderness, distention, 
peritonitis. In these cases we must operate and 
operate quickly, — open, wash, suture, drain. 1 These 
cases of acute ulcer are seen most commonly in young 
women, and the proportion of women to men is as three 
to one. It is said that they tend spontaneously to heal. 
Of this generally accepted statement, however, it is diffi- 
cult to find the proof, and if proof there be, it is impos- 
sible to foretell what sequelae may develop. 2 

However this may be, the chronic ulcers are commonly 
seen at a later age and more frequently in men, the 

1 Riegel, loc. cit., p. 594. " The change in the condition of the patients 
is very rapid. They fall into collapse, they look very ill, the pulse is 
small and threadlike, cold perspiration breaks out, and the extremities 
feel very cold. Peritonitis itself causes few symptoms, and all the signs 
of this condition are usually masked by the general symptoms we 
described. The temperature rises only a little, and may occasionally 
become subnormal. Traube was the first to call attention to the fact 
that vomiting is usually absent in cases of free perforation. The absence 
of vomiting may be considered an important diagnostic sign." 

2 Finney has collected from the literature 268 cases of perforating 
gastric ulcer : 139 recovered and 129 died, a mortality of 48 per cent ; 
and of the 21 more recent cases, 13 recovered and 8 died, a mortality of 
38 per cent. 



108 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

proportion here being three men to one woman. If we 
accept the statement that acute ulcers in women are 
found between the ages of twenty and thirty, we must 
recognize that the chronic ulcers in men occur between 
the ages of thirty and fifty. One difficulty in all this 
reasoning is that there is no satisfactory evidence to 
show that acute ulcers may not linger to become sub- 
acute and eventually chronic, and these considerations 
lead us to ask the old question, not yet satisfactorily 
answered, What is the cause of gastric ulcer ? 

It does not fall within the scope of this book to dis- 
cuss at length the much-debated question of etiology, 1 
but a few words on the subject seem necessary. The 
literature is enormous; a recent writer gives a bibli- 
ography of some one hundred and seventy -five names, 
and his list is only partial. 2 Traumatism seems to enter 
into the problem, and it is certain that hemorrhage into 
the gastric mucosa may be caused by a fierce blow. It 
is also certain that there may be a loss of substance 
from any mechanical cause, and that ulcers may then 
develop. We know from statistics that ulcers are most 
commonly found in the lesser curvature of the stomach 
and in the region of the pylorus, — the portion nearest 
the bile ducts, as well as the part usually injured when 
the organ is subjected to external violence, especially 

1 W. J. Mayo (Journal of American Medical Association, Vol. XLII, 
p. 1547) gives in a few trenchant words the gist of the matter : " Mechan- 
ical injury of the pyloric portion and excessive acidity of the gastric 
secretions, under anaemic conditions, give rise to ulcer and lie behind the 
pre-cancerous lesions which Ochsner notes are found in the history of 
cancer of the stomach in the majority of cases." (" Mechanical injury " 
means often irritation due to gall-stone disease.) 

2 Kiegel, Iqc. cit., pp. 543 et seq. 



ULCER OF THE STOMACH AND DUODENUM 109 

if the stomach is distended with food or gas. It is 
stated by one writer that " the reason for this [suscepti- 
bility to violence] is that this portion of the stomach is 
in close proximity to the unyielding spinal column." 

Leube, in his essay on diseases of the stomach, pub- 
lished in Ziemssen's Handbook for 1878, says, " A weak 
constitution, chlorosis, and anaemia predispose more to 
ulcer than a vigorous body ; " and we know certainly 
how clinicians have established the fact that chlorotic 
and anaemic subjects are more predisposed to ulcer than 
are robust and healthy subjects. And Riegel says : " We 
shall see that hyperchlorhydria does not lead to the 
development of chronic ulcer, but that it plays an im- 
portant role in preventing its cure. If we conceive that 
hyperchlorhydria is present in the majority of the cases 
of chlorosis, this alone may explain why ulcer of the 
stomach and chlorosis are so frequently found together." 

Then there is that factor of alcohol, — but this is not 
proven to be an important element in the etiology of 
gastric ulcer. 

It seems probable that extensive burns of the skin 
are sometimes followed by gastric and duodenal ulcers, 
the latter being more common than the former ; while 
Letelle and others have pointed out the possibility of 
ulcer being due to infection. 

As early as 1855, Virchow called attention to the 
importance of circulatory disturbances in the etiology 
of ulcer, and somewhat later Claude Bernard pointed 
out the probability that an abnormal increase in the 
acidity of the gastric juice could cause ulcer of the 
stomach, even though the alkalescence of the gastric 
mucosa remained normal. 



110 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Leube believes in the coincidence of two elements 
that lead to erosion, namely, anaemia and temporary 
abnormal acidity of the gastric juice, — and claims that 
both these factors must be present in order that chronic 
ulcer of the stomach develop. 

Here is an interesting quotation from Riegel's article : 
" I have always maintained that the reasons why cir- 
cumscribed areas of the stomach are digested and an 
ulcer is formed as soon as the circulation is interrupted, 
is not that the secretion of the tissues becomes acid 
instead of neutral, but that trophic changes occur ; that 
the tissues are not sufficiently nourished, and conse- 
quently die. Dead tissue is naturally digested by the 
gastric juice. We know that gastric juice does not 
destroy delicate layers of epithelium during life; as 
soon, however, as life ceases, the gastric juice acts on 
the dead tissue in the same way as it acts on the ingesta. 
Autodigestion of the stomach, during life, is impossible. 

" In conclusion, I repeat it is not so wonderful that 
ulcers are formed in the stomach, as that round ulcers 
of the stomach are so difficult to cure in healthy persons 
and in normal animals, whereas ordinary injuries of the 
gastric mucosa heal with such rapidity. The reason for 
this is nothing more than abnormal irritability of the 
secretory organs of the stomach, that manifests itself in 
hyperchlorhydria." 

A further and extremely interesting suggestion is 
embodied in the following words of Stockton : " The 
object of this paper is to suggest that by the influence 
of some process analogous to herpes, or to idiopathic 
hematoma auris, or to Raynaud's disease, or to herpetic 
gangrene, — some distinct and persevering nerve-pertur- 



ULCER OF THE STOMACH AND DUODENUM 111 

bation, — we may best explain the recognized and una& 
counted for feature of the clinical history as to location, 
age, and sex." 1 

We have already noted that the pyloric area is the 
common seat of ulcer, and this is a well-established 
observation ; but a multiplicity of ulcers in the same 
stomach and duodenum is not generally appreciated. 
The figures of Brinton are frequently quoted, in which 
he gives a list of four hundred and sixty-three cases, 
fifty-seven of which had two ulcers, sixteen had three, 
three had four, two had five, and four had more than 
five, — that is to say, 19 per cent of these cases had 
two or more ulcers. 2 If anything, clinical experience 
goes to show that Brinton's estimate of multiplicity is 
too low, and it is certain that ulcers recur frequently in 
the same organ. We see stomachs with several scars in 
them, and we see an open ulcer associated with old scars. 
How many of these may have been active processes at 
the same time it is impossible to say ; but it is fair to 
assume, from a large series of rather unsystematized ob- 
servations, that multiple ulcers of the stomach, as well 
as of the duodenum, are not uncommon. One object of 
an early operation is not only to cure the ulcer present, 
but by drainage to anticipate a tendency to subsequent 
ulcer formation. 

Granted, then, that peptic ulcers are due to a local- 
ized necrosis of the mucosa, acted upon by the digestive 
juices, and that the ulcers may be single or multiple, 
the wonder should be not that they are chronic and ob- 

1 Charles D. Stockton in Medical News, Jan. 14, 1893. 

2 W. J. Mayo, loc. cit. : " In 20 per cent of cases more than one ulcer 
is present." 



112 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

stinate, but that they heal at all. Their size and shape 
are various, the term round ulcer is not often applicable ; 
they may go on extending and destroying very consider- 
able areas, eating into the submucosa, the muscularis, 
the serosa, and even into neighboring organs, giving rise 
to extensive and serious complications. As a rule, how- 
ever, and as physicians meet them, they are limited and 
amenable to treatment ; for, provided they are recent 
and have not destroyed the muscularis, they may heal, as 
is shown by the frequency of ulcer scars. As Hauser 
has pointed out, healing occurs by regenerative prolifera- 
tion of the connective and glandular tissues that are in 
immediate proximity to the defect. The cells of the 
mucosa near the margin of the ulcer chiefly undergo 
proliferation. Hauser frequently found a large number 
of tubules in the centre of scars. The tubules were 
placed vertically to the epithelial surface ; some of 
them, however, ran diagonally and others parallel to 
the mucosa. They were either as broad as ordinary 
gland tubules or they were in a state of cystic dilata- 
tion. They were not lined by glandular epithelium, 
but by a species of cylindrical epithelium. None of 
these tubules had an open lumen. Hauser states that 
these peculiar structures no longer perform a secretory 
function, but are merely adenoid neoplasms. This last 
statement is extremely interesting in connection with 
the subject of malignant growths in the stomachs of 
persons previously subjects of ulcer. 

Those ulcers which do not heal must obviously be- 
come the source of chronic invalidism in their further 
course. 

There seems to be no good reason not to accept the 



ULCER OF THE STOMACH AND DUODENUM 113 

statement of numerous writers, that hyperchlorhydria is 
the result of ulcer present, for it is fair to assume that the 
lesion may well keep up a condition of irritation lead- 
ing to the excessive secretion of HC1. So we have a 
vicious circle, — the HC1 is necessary for the mainten- 
ance of the ulcer, and prevents its healing ; the ulcer 
in its turn stimulates the excessive production of 
the HC1. 1 

It used to be thought that hyperchlorhydria was the 
cause of " heartburn," but this has been demonstrated 
to be untrue. Pyrosis is due to gastric fermentation, 
usually. Then, there is that word dyspepsia, a symp- 
tom difficult of definition. If we mean a disturbance 
of digestion, and that digestion is rendered more diffi- 
cult or retarded, we can hardly call ulcer a cause of 
dyspepsia ; for in ulcer, stomach digestion is often 
expedited rather than retarded, and this is due to the 
presence of hydrochloric acid in excess. Of course 

1 J. A. Vieregge in the St. Paul Medical Journal, Vol. X, p. 133, 
quoting A. Matthiew and I. Roux (Gazette des Hopitaux, 1903, No. 66), 
says : " The chemistry of the stomach is of special importance in three 
or four different pathological conditions ; namely, ulcer, carcinoma, and 
gastritis or dyspepsia. In carcinoma free HC1 is quite often absent 
and the combined HC1 is present in small quantities only. The change 
is due to an atrophy of the mucous membrane. It is, however, not 
pathognomic for carcinoma, and may be found in other affections. The 
hypochlorhydria, then, only speaks for carcinoma when it is associated 
with other symptoms. In other cases the carcinoma has developed from 
an ulcer or the scar of an ulcer. In the latter affection there is mostly 
present hyperchlorhydria, which concerns the free HC1 as well as the 
combined HC1. It is of the greatest importance to settle this question 
when there is any doubt about the nature of the affection. Nevertheless, 
the hyperchlorhydria of ulcers is of the same importance as the hypo- 
chlorhydria of carcinoma. Therefore, hyperchlorhydria, with a certain 
amount of stasis and hypersecretion, on an empty stomach in the morn- 
ing, is almost pathognomic for pyloric ulcer." 
I 



114 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

there are exceptions, as in the case of an associated gas- 
tritis or dilatation, with pyloric obstruction, when food 
remains overlong in the stomach, and thus causes 
heartburn. 

From this brief account of the nature of ulcer, it is 
apparent that its duration is uncertain, and its prospect 
of healing equally so ; that we must often fail of mak- 
ing the diagnosis ; and that many cases of faulty diges- 
tion are long continued without ulcer as the cause being 
suspected. Indeed, it seems more and more probable, 
from whatever viewpoint we approach the problem, 
that peptic ulcer is not an uncommon condition. Let 
us then attempt briefly in some fashion to formulate 
our ideas regarding 

Diagnosis. — No single symptom is sufficient in itself 
to establish the diagnosis ; we must look for a symptom- 
complex, and the symptom-complex many times is lack- 
ing even after patient search. 

The questions of erosions and acute ulcers need not 
detain us, for either such conditions are relieved spon- 
taneously and by the patient's own care of himself, or 
the symptoms are so alarming that with the factors 
age, hemorrhage or pain, and collapse, the diagnosis is 
obvious and the line of treatment clear. 

It is with chronic ulcer that we are at present con- 
cerned, and it is chronic ulcer which is commonly meant 
by writers discussing ulcer. 

Here is a suggestive little paragraph from an article 
by M. C. Millet, 1 suggestive because it seems to explain 
the views of many clinicians, — suggestive rather than 
instructive or convincing : " Clinically we may classify 

1 St. Paul Medical Journal, p. 193, 1903. 



ULCER OF THE STOMACH AND DUODENUM 115 

chronic gastric ulcer as the gastralgic, catarrhal or 
vomiting, dyspeptic, hemorrhagic, or cicatricial form, 
according to the prominence of individual symptoms." 
Such a classification is well enough, perhaps, though a 
little confusing, for " dyspeptic " and " catarrhal " seem 
to be much the same thing, and " vomiting " is often 
quite distinct from either of the other two. 

Pain 1 is usually regarded as present in nearly all 
cases of ulcer, — thus Greenough and Joslin say, " The 
pain was definitely located in practically all the cases," 
and Riegel says, " The most prominent symptom of 
ulcer is pain." Doubtless this is true in cases of ulcer 
clearly diagnosticated, but we must remember that 
ulcer sometimes develops slowly, that it is often 
secondary to bile-duct disease, that it may heal spon- 
taneously, that in a number of cases pain may not 
be present (indeed, in Greenough and Joslin's list it was 
absent in fourteen of their one hundred and eighty- 
seven cases), and that an obscure case must be rele- 
gated to Millet's class Dyspeptic. In the beginning 
of ulcer there is merely a feeling of distress after eating, 



1 Situation of Pain 



Epigastrium 

Epigastrium and back 

Epigastrium, back, and chest 
Epigastrium, back, and right costal border . 
Epigastrium, back, and left hypochondrium 
Epigastrium, back, and right hypochondrium 
Epigastrium and left hypochondrium 
Epigastrium and chest . 
Epigastrium and between shoulders 
Epigastrium and left shoulder-blade 
Epigastrium and umbilicus . 

Total epigastrium and elsewhere 



23 
2 
1 
5 
2 
8 
4 
2 
3 
1 



91 



51 



142 



116 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

and this condition may exist for many years without 
developing further symptoms. Indeed, in the condition 
of gastrectasis have we not seen that many cases with 
pyloric obstruction, undoubtedly due to ulcer, never 
develop further symptoms beyond distress ? Pain, then, 
may be a late symptom. When present, it appears in 
paroxysms ; it is usually strictly localized. 

There are exceptions, however, to the paroxysmal 
character ; in some cases discomfort amounting to pain 
may constantly be present, and in such cases we must 
suspect a circumscribed peritonitis and adhesions 
causing pain. Pain may therefore be associated with 
certain positions of the body, for standing or turning 
on one side may cause dragging on adhesions. So we 
must distinguish two pains : the pain of ulcer jper se 
and the pain resulting from a local peritonitis. 

It is in association with food, however, that char- 
acteristic pain is seen. Immediately upon taking food 
an increased secretion of gastric juice takes place, and 
the ulcer becomes irritated either by the acid directly, 
or mechanically by the peristaltic movements of the 
stomach. 

We will grant that the character of the pain has 
established for us with fair certainty the presence of 
ulcer ; but can we, from its location and time of onset, 
answer another leading question, Where is the ulcer ? 
Our conviction is that we cannot do this with any cer- 
tainty. We may be able to differentiate duodenal 
ulcer from gastric ulcer, for in duodenal ulcer the pain 
is said to come on late and to be in the back often ; 
but when it comes to locating accurately ulcer within 
the stomach cavity proper, there are many sources of 



ULCER OF THE STOMACH AND DUODENUM 117 

error. Granted that in more than 75 per cent of the 
cases the ulcer is in the pyloric area, or ulcer-bearing 
zone, it does not necessarily follow in that case that 
pain will be delayed longer than when the ulcer is in 
the greater curvature or the cardia. The size of the 
ulcer, the amount and character of food, the degree of 
hyperacidity, the position of the stomach, all enter into 
the problem of the production of pain ; and after all, 
practically, for purposes of treatment, accuracy in deter- 
mining the seat of lesion is not essential. 

And pain may be due to cicatrices. Especially is 
this so when we have to deal with stomachs distorted, 
narrowed, or displaced. Food enters into such a stomach, 
and from its attempt properly to deal with the food, 
pain frequently results. 

A great deal has been said and written about ten- 
derness on pressure, — about the location of such 
tenderness, its intensity, the extent of the painful area, 
and what it all means, — but such writing is not con- 
clusive. We can say, however, that in gastric ulcer the 
same tenderness is nearly always present in the same 
individual. 

Much has been written also about dorsal pain on 
pressure. Cruveilhier talked about it nearly seventy 
years ago. Boas says that it is present in about one- 
third of all gastric ulcer cases ; it is often associated 
with epigastric tenderness and is situated a little to the 
left of the dorsal vertebrae, between the seventh and 
the twelfth spines ; and all this is helpful in forming 
a diagnosis. 

So much for pain, which, as a definite symptom, is 
not at all satisfactory evidence of the presence of active 



118 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

gastric ulcer, for exactly similar pain may be due to 
disease of the bile passages and to pancreatitis. 

Vomiting is a symptom more important than pain, 
we are convinced, though Riegel says it is not con- 
stantly present. On the other hand, Greenough and 
Joslin found it absent in but four cases out of their 
one hundred and eighty-seven cases, and Welch says 
that next to pain it is the most frequent symptom of 
gastric ulcer. Ordinarily it is associated with pain ; 
it comes on some hours after eating and results in the 
relief of pain. There are causes for vomiting other 
than gastric ulcer, but the same is true of pain ; it is a 
peculiar combination of pain relieved by vomiting 
which we regard as characteristic. 

It is the vomiting of Mood, however, which gives us 
the symptom erroneously regarded by many as pecul- 
iarly characteristic of ulcer. As we have already 
pointed out in this chapter, authors differ widely as 
to its frequency, and the figures range from 28 per 
cent to 90 per cent of all cases. Here, again, the cli- 
nician is forced to the conviction that mere autopsy 
records, or even clearly proved clinical records of ulcer 
cases, do not tell the whole truth. In a series of fifteen 
cases, which we have seen recently demonstrated as 
ulcer beyond peradventure by scars found at operation, 
only one case gave a history of vomiting blood ; and 
other operators tell the same story. 

The character and the amount of the blood lost are 
not particularly significant. 1 Small amounts of par- 

1 Greenough and Joslin's tables of one hundred and eighty-two cases : 
one hundred and forty-seven vomited blood ; in eighty-six of these cases 
the hemorrhage produced constitutional symptoms, in only nineteen 



ULCER OF THE STOMACH AND DUODENUM 119 

tially digested blood, — the familiar " coffee-ground " 
vomiting, mean no more than large amounts of bright 
blood. One is due to capillary oozing, the other to the 
erosion of vessels. 

Again, very severe hemorrhage, leading even to the 
death of the patient, may occur from gastric ulceration 
near the pylorus or from duodenal ulcer ; yet no vomit- 
ing may result, the blood being passed off by the bowel 
in such cases. When copious, it is usually detected in 
the stools. We must be on our guard, however, against 
trusting to the patient's statements ; for small amounts 
of partially digested blood in the stools can be recog- 
nized only by the expert. And, too, haematemesis gives 
no clear idea of the location or extent of the ulcer. 

Dyspeptic symptoms, as we have said, cannot be 
trusted as evidence of active ulceration. Dyspeptic 
symptoms, long continued, are always suggestive, how- 
ever, especially when they are not relieved by treatment ; 
and it cannot too often be repeated that the scars left 
by a healed and unsuspected ulcer are frequently the 
cause of long-standing dyspepsias. 

Fever is not a symptom of ulcer, but we must remem- 
ber that the presence of fever is no indication of the 
absence of ulcer. Fever may be due to complications 
from deep extension of the process, or to perforation 
associated with localized peritonitis. 

It does not seem necessary to refer again to the ques- 

cases did hemorrhage precede symptoms of ulcer. There was fatal 
hemorrhage in seven cases, or 3.7 per cent ; and in three of this number 
it was the first symptom : males 17 per cent, females 1.27 per cent. 
From a study of ages, in fatal hemorrhage, they conclude that the 
younger the individual the less likelihood is there of death from hem- 
orrhage. 



120 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

tion of analysis of the stomach contents, beyond repeat- 
ing the well-recognized statement that if the analysis be 
made after a test breakfast, the secretion of gastric 
juice is found greatly increased, and that the time of 
digestion, in case the pylorus is not obstructed, is dimin- 
ished rather than increased. Often the stomach will be 
found empty one hour after the test breakfast. 1 

Riegel insists upon the fact that the results of the 
examination of vomitus are less significant than the ex- 
amination of the stomach contents removed by the tube 
after a test meal. " Any physician who has had occa- 
sion to examine many stomach cases knows that the 
analysis of the vomit always yields doubtful results, 
because so many sources of error exist." 2 

In the chapter on appendicitis we take the ground 
that chronic and recurring forms of that inflammation, 
rather than acute appendicitis, fall properly within the 
scope of this book. For the same reason we shall say 
little of that alarming catastrophe, perforation of the 
stomach, which may result from the presence of gastric 
ulcer. Perforation can scarcely be called a digestive 
disorder in the sense which would warrant an elaborate 
consideration of the subject here. The symptoms of 
perforation have already been described briefly, and 
the question of treatment will be dealt with later. 

Subphrenic abscess also is a complication which need 
only be mentioned in this connection, and the broad 
consideration of ulcer complicated by cancer will be 
taken up in a subsequent chapter. 

Sour-glass stomach — its causes, symptoms, and diag- 
nosis — deserves a few words. This condition is due 

1 See Appendix. 2 Riegel, loc. cit., p. 592. 



ULCER OF THE STOMACH AND DUODENUM 121 

usually to ulcer, and as such it should be ranked among 
the complications or sequelae of that disease. 

Riegel, in his elaborate essay, deals with the subject 
slightingly, for he calls it a condition that is occasion- 
ally congenital or which may result from ulcer ; and he 
makes the surprising statement that nearly all the cases 
of hour-glass constriction of the stomach which have so 
far been observed were found by chance at autopsy. 1 
He proceeds to remark that doubtless this condition 
could be diagnosticated during life in a majority of cases 
if the patients were examined with sufficient care. 

From such observations, it is evident that Riegel is 
not familiar with the English and American literature 
on the subject ; for a great deal of work has been done 
and extensive observations on hour-glass stomach have 
been made in those countries. Riegel does admit, how- 
ever, what we believe to be the fact, that hour-glass 
stomach is due to ulcer or other inflammatory processes 
and is seldom congenital. 

Moynihan has convinced himself that nearly all cases 
of hour-glass stomach are acquired ; 2 in this he differs 
from the Fen wicks, Meckel, Sandifort, Roger Williams, 
and numerous other writers whom he quotes, and his 
argument is an interesting and important one. After 

1 The following figures collected from the literature of the subject 
have been presented by Watson : twenty cases of congenital hour-glass 
stomach ; twenty cases of acquired hour-glass stomach not operated upon ; 
twenty-nine cases of acquired hour-glass stomach operated upon. Three 
gastroenterostomies with no deaths ; seventeen gastro-plasties with three 
deaths; six cases of gastro-anastomosis with one death; one case of in- 
version of the ulcer with one death ; one case of artificial gastric fistula 
with one death. 

2 " The Surgical Treatment of Gastric and Duodenal Ulcers," by 
B. G. A. Moynihan. Philadelphia, 1903. 



122 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

describing the claims of those who assert the congenital 
origin of such cases, Moynihan goes on to say : « With- 
out entering in detail into this discussion I may say 
that I have very carefully considered the question as to 
the existence of hour-glass stomach as a congenital de- 
formity, examining all the specimens that I could find 
and reading carefully the records of, I believe, all the 
published cases; but I remain confident in my belief 
that there is no evidence whatever which will establish 
the claim of those who assert that the disease is often 
congenital in origin. Since I first threw doubts upon 
the congenital origin of many of the cases of hour-glass 
stomach, and showed that, in almost all of the cases, 
obvious evidence of old ulceration could be found, sev- 
eral investigators have supported my conclusions by 
observations made during the course of operation, or on 
post-mortem examination. There is indeed no inherent 
improbability of the existence of congenital hour-glass 
stomach ; but it lacks proof." Few of us doubtless 
have had large experience in dealing with hour-glass 
stomach, and evidence of its congenital origin is rather 
negative. We have ourselves operated upon two cases 
of this condition, and both obviously were due to gastric 
ulcer. 

In general terms one may say the hour-glass con- 
traction is due to three acquired causes : — 

1. Ulcer, whether perforating and causing adhesions, or 
non-perforating. Those ulcers which cause adhesions 
may involve extensively portions of the stomach with 
neighboring organs, so that the lumen of the stomach 
may be nearly obliterated; this form of hour-glass 
stomach is far the most difficult to deal with by opera- 



ULCER OF THE STOMACH AND DUODENUM 123 

tion. The chronic ulcer which does not perforate may, 
however, cause an hour-glass constriction, and this per- 
haps is the form most commonly seen. If the ulcer is 
very extensive, nature's attempt at healing may cause 
an immense thickening with cicatricial contraction about 
the lesion, so that great deformity of the stomach may 
result. And we do not always find a clear history of 
ulcer even in these extreme cases. 

Some months ago we were consulted by a patient 
with a dilated stomach, who gave a history of having 
had for five years pain immediately after taking any 
form of food, even water. She had never vomited ; 
there had been no evidence of hemorrhage, and never 
any special tenderness ; there was marked hyperchlor- 
hydria, and she had been regarded by physicians as a 
dyspeptic of the hyperacidity type. The stomach was 
somewhat prolapsed and considerably distended. On 
opening the abdomen we found an hour-glass constric- 
tion of the stomach, about three inches from the 
pylorus, and on opening the stomach itself the dense 
cicatrix of an old ulcer was found as the obvious cause 
of the difficulty. 

Such cases as this confirm our frequent suspicion that 
serious malformation of the stomach, leading to the 
most distressing and dangerous symptoms, may long 
exist without the possibility of our making a diagnosis 
of ulcer. 

In this case we found a condition which Moynihan 
also has pointed out, namely, a narrowing of the 
pylorus. This narrowing was probably of short dura- 
tion, but that it frequently does exist coincidently with 
hour-glass stomach seems well established, and is a 



124 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

further argument in favor of our repeated contention 
that multiple ulcers are more frequent than figures 
show. 

2. Perigastric adhesions may cause hour-glass stomach. 
This condition as the cause of hour-glass stomach is 
probably much less common than is ulcer. We refer 
to adhesions due to old peritonitis of some source other 
than ulcer of the stomach, — tubercular peritonitis, in- 
flammation extending from the gall bladder, the pan- 
creas, the appendix, or even originating in the pelvis. 

3. Cancer of the stomach or some neighboring organ 
may cause the hour-glass deformity. Several such 
cases are reported. 

In spite of the opinion of Moynihan, we believe that 
it will always be difficult, in a great many cases, to 
establish the diagnosis of hour-glass stomach before 
operation. That writer says that of his first six cases 
only one was diagnosticated ; but that in his last eight 
cases, six were diagnosticated with certainty. Doubt- 
less the diagnosis may be made in those typical cases 
in which the constriction is near the middle of the 
stomach ; but when near the pylorus, as not infre- 
quently happens, diagnosis is often impossible. Indeed, 
in a case known to the writers, an hour-glass restriction, 
two inches from the cardiac orifice, was overlooked 
even at operation; and in the case reported on a pre- 
vious page, we doubt if the hour-glass constriction, three 
inches from the pylorus, could have been determined 
before operation. 

Writers describe various means for arriving at the 
diagnosis ; and four of these means have proved them- 
selves of value, 



ULCER OF THE STOMACH AND DUODENUM 125 

' 1. If the stomach be washed out until the water 
returns clear and there then follows a gush of foul 
fluid, it is probable that a second pocket exists ; or if, 
a few minutes after one thorough washing, the tube be 
reintroduced and a second supply of filthy detritus be 
obtained, that is further evidence. This is Wolfler's 
second sign. 

2. Wolfler's first sign is arrived at as follows : pass 
the stomach tube, wash out with a known quantity 
of water, and note the loss of a certain amount. The 
portion of the water not returned has escaped into the 
second cavity of the stomach. 

Both of these methods have repeatedly led to error 
and every clinician knows that it is not possible, even 
when dealing with the normal stomach, always to 
secure again the full amount of water injected. 

3. Paradoxical dilatation, as it is called : shake the 
abdomen and obtain the splashing sound, then pass 
the tube, empty the stomach, and you will find splash- 
ing still to persist. This last splashing comes, of 
course, from the second pouch, which has not been 
emptied. 

4. Moynihan has a sign of his own which is useful. 
Map out the stomach resonance, give a Seidlitz powder 
in two portions ; after twenty or thirty seconds an 
enormous increase in the resonance of the upper part 
of the stomach can be found, while the lower part 
remains unaltered. Later the lower pouch may be seen 
to fill up. 

As we have said, we know nothing characteristic in 
the symptomology of these cases. After all devices the 
diagnosis remains difficult, and not infrequently it will 



126 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

be found at operation that an unsuspected hour-glass 
stomach presents itself. 

DUODENAL ULCER 1 

Etiologically, duodenal ulcer must be regarded as in 
the same class with gastric ulcer. 2 It arises from the 
same causes, 3 and it presents similar appearances. But it 
is a graver lesion because the duodenum is of a very much 
thinner and more delicate structure than the stomach, 
consequently the blood-vessels are more easily eroded. 
More than that, it does not so often cause noticeable 
symptoms, though we are coming to see that frequently 
it may be mistaken for disease of the bile passages. 

The same questions and doubts about the frequency 
of duodenal ulcer and its multiplicity meet us as when 
we dealt with gastric ulcer ; and, further, writers dis- 
agree as to its frequency relative to gastric ulcer. Cer- 
tainly, duodenal ulcer seems to be the less common of 
the two, and the relation, as reported by writers, varies 
all the way from one in nine to one in forty. Ulcers of 
the stomach and duodenum are not infrequently found 
present in the same individual. 4 

1 Bibliography : A. Krauss, a monograph covering the literature of 
duodenal ulcer up to 1865 ; Chvostek, the literature up to 1882 ; Oppen- 
heimer, literature up to 1891. Perry and Shaw, Guy's Hospital Reports, 
1893 ; Cullen, Scotland Medical and Surgical Journal, 1897, Vol. I, p. 635 ; 
Samuel and Soltau Fenwick, " Ulcers of the Stomach and Duodenum," 
1900 ; Hemmeter, " Diseases of the Intestines," 1901, Vol. I. 

2 W. J. Mayo, loc. cit. : " The only portion of the duodenum in which 
we are interested is the four inches lying between the pylorus and the 
papilla of the common duct of the liver and pancreas. This may be 
called the vestibule of the small intestines." 

8 How frequently it is due to extensive superficial burns we know not. 
Who has seen many such cases ? 

4 " Chvostek remarks that the statement made by many authors, 



ULCERS OF THE STOMACH AND DUODENUM 127 

Variations in the locations of the ulcers are described 
by writers, but the ulcers' most frequent and important 
site is in the first four inches of the duodenum. 

Ulcers forming in the portion of the duodenum below 
the ampulla of Vater, though rare, may cause a variety 
of complications in their healing, the most striking of 
which is partial or complete cicatricial closure of the 
duct, with consequent icterus, or atrophy of the pancreas 
from stasis. 

Those ulcers nearer the pylorus, however, are far 
the most important for our consideration. They are 
important, not so much for their early symptoms, as for 
the frightful danger of their presence. Ulcer of the 
stomach is bad enough, because it may lead to chronic 
invalidism ; ulcer of the duodenum is worse, because it 
may lead to sudden death. Frequently it may give rise 
to fatal hemorrhage, it may result in perforation and 
involve other organs, and it may result in cancer. 1 

Pain is not necessarily present with duodenal ulcer, 
or it may be continuously present ; when continuous, 
the pain is probably due to circumscribed peritonitis 
rather than to the ulcer itself. As we said in compar- 
ing gastric with duodenal ulcers, it is generally supposed 
that pain in the latter comes on from four to six hours 
after eating ; but this assumption is not a safe one, for 
pain may be early or late in either form of ulcer. 

among them Krauss, that cicatrized duodenal ulcers are relatively rare, 
is not correct; and that the comparative rarity of this condition is 
only apparent, and due to the fact that cases in which cicatrices are 
found by chance during autopsy, but in which symptoms were absent 
during life, are not published." — Nothnagel, in " Diseases of the Intes 
tines and Peritoneum," p. 241. 

1 The Fenwicks have collected ten examples of this complication. 



128 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Patients with duodenal ulcer alone do not often 
vomit; but frequent vomiting does not rule out this 
condition, for coincident gastric ulcer may be present. 

Analysis of the gastric contents gives no light as to 
the presence or absence of this condition. The chemists 
vary much in their statements. 

There may be hemorrhage, shown either as haematem- 
esis or melena ; and the Fenwicks state that the latter 
is not necessarily more common than the former ; they 
put the percentage of hemorrhage at 26 in recent duo- 
denal ulcers, and at 40 in chronic duodenal ulcers, the 
death rate from hemorrhage being variously estimated as 
from 13 to 36 per cent. Now except for symptoms simu- 
lating cholelithiasis, these are all the symptoms that 
can be produced by ulcer of the duodenum as distin- 
guished from ulcer of the stomach, and it is apparent 
that a positive differentiation rarely is possible. The 
location of the pain is not distinctive, the bloody stools 
are not distinctive, and of the other signs the variation 
is nil. 

Perforation from duodenal ulcer is so grave a mis- 
fortune that we must think of it as distinct from the 
perforation of gastric ulcer. It is apparently more 
sudden because less likely to be preceded by symptoms. 1 
Both, commonly, are fatal if untreated. Until recently 

1 T. C. English in the Lancet for December 19, 1903, describes a series 
of fifty operations for perforation, with a mortality of 52 per cent. Five 
of his cases had had no previous gastric symptoms of any kind. He 
points out that in a great majority of cases the onset is sudden and 
without warning. The situation of the pain is no guide, as it is often 
most intense in the lower portion of the abdomen. Contrary to the 
experience of most writers, vomiting occurred in 75 per cent of his cases. 
He describes the pain as " sudden," " terrible," " intolerable," — a pain 
such as rarely is met with in any other condition. 



ULCER OF THE STOMACH AND DUODENUM 129 

many of these duodenal perforations went unrecognized 
until too late for operation ; though perforation of the 
appendix, with a similar train of symptoms, seems no 
longer to offer difficulty in diagnosis to practitioners. 
However, we believe that to-day all physicians of any 
experience realize the serious nature of symptoms suggest- 
ing even remotely perforation of organs in the upper por- 
tion of the abdomen. All surgeons have recognized the 
marked similarity between the symptoms of perforation 
of duodenal ulcer and those of a perforated appendix. 
Not only are the evidences of shock and collapse, with 
a spreading peritonitis, much alike in both ; but the 
area of pain and tenderness in both is often below the 
umbilicus. We must realize that such pain and tender- 
ness in the right inguinal region following the perfora- 
tion of a duodenal ulcer are due to the fact that the 
infecting material from the duodenum is poured out 
over the right renal area, and by the action of gravity 
settles in the right flank and in the neighborhood of the 
appendix. Moynihan records forty-nine cases of per- 
forated duodenal ulcer, in eighteen of which the diagno- 
sis of appendicitis was made ; and such an experience is 
common to us all. Of course, such an error in diagnosis 
is of no serious importance if we follow the usual custom 
of operating in all these acute conditions. 

So far as we know, there can be no expectation of 
a cure in cases of duodenal perforations not operated 
upon. The operation, to be efficient, must be instant ; 
after eight hours' delay the prognosis is very grave. 
Opening the abdomen, suturing the perforation, supra- 
pubic pelvic drainage, and after treatment in a sitting 
position have reduced the mortality below 20 per cent, 



130 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

according to Mayo's figures. With these recoveries is 
associated apparently the healing of the ulcer. 

MEDICAL TREATMENT OF PEPTIC ULCER 

We do not propose advocating any special form of 
treatment for gastric ulcer ; but we do most earnestly 
add our word to the words of many careful observers, 
in Europe and in this country, who have come to feel 
that reliance upon internal treatment in these cases 
often is vain. From what we have said of the site, 
appearances, progress, and depth of ulcers, this conclu- 
sion seems inevitable. There are many things about an 
ulcer which we cannot ascertain when it is hidden in 
the stomach or duodenum. We cannot tell how many 
ulcers there are ; we do not know how deeply the ulcer 
may have gone ; we cannot be sure of the extent of cica- 
trices ; we cannot make certain of the absence or pres- 
ence of adhesions, and for a time, at least, of the partial 
closure of the pylorus. 

Then there is that impossibility of determining, with 
the subsidence of symptoms, whether or not our ulcer 
truly is healed. Robson and Moynihan well put the 
matter when they say : " It is useful to hold in view the 
course of an ulcer of the leg, which, directly the healing 
stage has arrived, becomes free from pain. But this 
neither indicates that healing is completed, nor that 
care may cease." 

It does not seem necessary here to elaborate the mat- 
ter of medical treatment. The main principle in such 
treatment is physiological rest. Clinicians differ as to 
details when they talk of means of securing rest, but in 
all cases rest is the one great desideratum. 



ULCER OF THE STOMACH AND DUODENUM 131 

Since the work of Cruveilhier the rest cure has been 
the recognized method of procedure, and that author 
himself constantly asserts that this is the fundamental 
condition for a complete cure of ulcus ventriculi. Such 
has been the teaching and the practice of sound clini- 
cians for the past seventy years, and we see that their 
purpose must be to secure quiet for the stomach and to 
banish hyperchlorhydria. We have seen how excessive 
acidity is due in great part to gastric activity, induced 
by food; and the conclusion, therefore, is obvious that 
so far as possible we must limit or banish stomach feed- 
ing. The limitation of such feeding can secure only 
partial results, as the blandest foods in least amounts 
must necessarily increase motility and stimulate the out- 
put of hydrochloric acid. 

During the past fifteen years rectal feeding has come 
to take the place of limited gastric feeding in the clinics 
of many physicians — rectal feeding persisted in for a 
short time only. The discussion of these two methods 
is needless here ; suffice it only to say that, though un- 
equally successful in securing absolute gastric repose, 
they are practically equally successful in the number 
of cures attained. 

The most interesting figures bearing upon the subject 
are those published in 1899 by Greenough and Joslin. 
As we have heard already, they studied some one hun- 
dred and eighty-seven cases, divided nearly equally be- 
tween two " services " at the Massachusetts General 
Hospital. In the one service it was the custom to 
feed by nutrient enemata during the first few days. 
In the other, rectal feeding was employed in the more 
severe cases only, the diet being limited ordinarily 



132 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

during the early days to milk and lime-water by the 
mouth. 1 

On the average the patients fed by nutrient enemata 
were on that treatment for 8.39 days ; and the shortest 
period was one day. 

The results of these two methods of treatment were 
as follows : twenty patients, or 32 per cent, who re- 
ceived no food by the mouth were cured ; forty-two 
patients, or 68 per cent, who received no food by the 
mouth were not cured ; twenty-three patients, or 44 
per cent, who received food by mouth were cured ; and 
twenty-nine patients, or 56 per cent, who received food 
by the mouth were not cured. These conclusions re- 
fer to the condition of the patients at the time of their 
leaving the hospital ; from which it appears that only 
32 per cent of those who received no food by the mouth 
were cured, in contrast to 44 per cent of cures in those 
patients who were given small quantities of milk and 
lime-water from the outset. These writers point out 
the fact, however, that it was chiefly the severe cases 
which were put on nutrient enemata alone, and that this 
fact directly tended to make a less favorable showing 
for the starvation method. Furthermore, it is interest- 
ing that the. patients who were starved remained a 
longer time in the hospital on the average than those 
who were fed small amounts of milk and lime-water. 



1 The following table shows figures : — 



Sebvice A Service B 



Total 



Number of cases with no food by mouth . 
Number of cases with food by mouth 
Doubtful 



71 

23 

o 



31 

60 





102 

83 

2 



ULCER OF THE STOMACH AND DUODENUM 133 

Other observers seem to have felt greatly encouraged 
by such methods of treatment, whether with or without 
rectal feeding ; but all of them naturally draw a sharp 
distinction between the results in the cases of recent 
ulcers and chronic ulcers. In dealing with recent ulcers 
the figures are far the more favorable ; while in the case 
of chronic ulcers, though relief is experienced often for 
a time, relapses are frequent. And we must bear in 
mind that it is among young women chiefly that we 
see the favorable cases of recent ulcer cured ; whereas 
it is among middle-aged men that we see more com- 
monly chronic ulcers relieved merely. 1 So it comes 
down to this, that to talk about the results of treatment 
in ulcer cases as a whole must be unsatisfactory and 
misleading. A great range of investigations shows that 
immediate cures, so called, are found in from 60 per cent 
to 90 per cent of the cases ; but owing to the obscurity 
of conditions actually present in any given stomach or 
duodenum, it is very difficult to assign cases to a par- 
ticular class. In general terms, however, one is safe in 
assuming that a young woman with a recent ulcer stands 
a good chance of being cured by the rest treatment ; 
while an older person, whether man or woman, with 
evidences of long-standing ulcer is unlikely to receive 
more than temporary benefit by such measures ; and 

1 " Opinion is divided as to whether rectal alimentation increases or 
diminishes gastric secretion. Following the observations of Winternitz, 
it was believed that the gastric acidity was increased by nutrient enemata, 
but the studies of Ziarko go to show that the acidity of the gastric juice 
is really decreased by rectal feeding. Bourget, on the other hand, dis- 
cards rectal feeding, believing that food thus introduced is but slightly 
absorbed and that by reflex action it increases gastric secretion." — 
Charles G. Stockton in Riegel's "Diseases of the Stomach," p. 628. 



134 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

the discussion in our Chapter IV shows us what may 
be the after-history of this latter class of cases. 

Taking the whole number of peptic ulcer cases as a 
group, what are we to tell these people about their 
future ? This is a question less difficult to answer now 
than it would have been ten years ago ; a few sets of 
statistics by medical investigators give us some informa- 
tion, and the operative findings of surgeons tell us even 
more. J. W. Russell, in the Zcmcet for January 30, 1904, 
gave some interesting figures. He had been able to trace 
the after-history of forty-seven gastric ulcer cases ; the 
time elapsed since their leaving the hospital being from 
two to thirteen years, he found that the immediate mor- 
tality was 2.1 per cent as compared with Greenough and 
Joslin's 8 per cent. Russell also found that 42.6 per 
cent of his cases ended in recovery, 27.7 per cent having 
had but a single attack, whereas 14.9 per cent recovered 
after one or more relapses ; 44.7 per cent were suffering 
from stomach symptoms of more or less severity at the 
time of their last report; 15 per cent were the victims 
of repeated attacks with intervals of immunity ; while 
30 per cent were suffering from almost continuous pain. 
From such studies Russell concludes that in many cases 
of chronic ulcer medical treatment is proving unsatis- 
factory. 

Wagner of Hamburg 1 writes on the end-results of the 
medical treatment of gastric ulcer, and his conclusions 
differ somewhat from those of Russell. He has some- 
thing to say about the technique, remarking that his 
purpose is to abolish hyperchlorhydria and cure the 
anaemia in order to insure permanent health. He gives 

1 Munich med. Wochen., LI, 1903. 



ULCER OF THE STOMACH AND DUODENUM 135 

his patients concentrated albumen by the mouth and 
does not use nutrient enemata. He reports sixty 
cases, but has been able to follow only twenty-five of 
them ; and in all of these twenty-five there had been a 
history of haematemesis. His treatment consisted in 
four weeks of absolute rest in bed with an ice-bag to 
the stomach. If hemorrhage occurred, the diet was re- 
duced to drachm doses of iced milk, gradually worked 
up until ten ounces at a time could be taken ; after which 
one to three beaten-up iced raw eggs were given. He 
prescribed bismuth in ten to fifteen grain doses daily, for 
ten days after the hemorrhage. By that time the patient 
would be taking daily eight raw eggs, two quarts of milk, 
rice, rolls, and chopped beef. 

Of the twenty-five cases which were followed to the 
end, eighteen, or 72 per cent, were reported in good health, 
but the length of time since their leaving the hospital was 
not given ; while of the remaining seven cases, one had 
occasional pain, three had had some pain after leaving 
the hospital, and two had had subsequent hemorrhages. 
The report is rather unsatisfactory, as the time elapsed 
since the hospital discharge is not given. 

The general impression one gains from the figures of 
Russell and Wagner is, that a considerable proportion 
of ulcer cases relapse. It is unfortunate that more 
research work of this kind has not been done ; but one 
turns with satisfaction to the often quoted paper of 
Greenough and Joslin. So far as we know their figures 
on end-results are the best that we have, and their con- 
clusion, that we must not look to immediate hospital 
results as final, is the only logical conclusion. 

Of those one hundred and eighty-seven cases studied, 



136 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

these writers were able to report upon one hundred and 
fourteen after intervals averaging five years ; and their 
figures are so striking that we shall quote them in con- 
siderable detail. 

Of the one hundred and eighty-seven cases, the results 
at the conclusion of hospital treatment are summarized 
in the following table : — 

Cured 121 64 per cent 

Relieved 34 18 per cent 

Deaths 15 8 per cent 

Otherwise 17 9 per cent 

Then take the one hundred and fourteen cases which 
were traced after leaving the hospital. 





Kecurbence 


Dead 


Cubed 


Total 


63 Cured . . .55 per cent 

29 Relieved . . .25 per cent 

15 Deaths . . .13 per cent 

7 Otherwise ... 6 per cent 


28 
10 

3 


8 
4 

3 


27 
15 

1 


63 
29 

7 


114 


41 


15 


43 


99 



After an average period of five years the following 
condition was found to exist : — 



Cured 43 + 3 

Not cured — Recurrence 

Deaths 15 + 8 . 

Deaths, cause unknown 



46 


40 per cent 


41 


36 per cent 


23 


20 per cent 


4 


4 per cent 



114 



We are told that the mortality was much higher 
among men than among women, being 30 per cent 
among the former and only 9 among the latter. The 
writers note the striking difference between these fig- 
ures and those of other reporters. 



ULCER OF THE STOMACH AND DUODENUM 137 

At the Massachusetts General Hospital the immediate 
total mortality was 8 per cent, while Leube gives an im- 
mediate mortality of 2 per cent, which suggests a more 
severe type of disease at the Boston hospital, especially 
when we consider that there the percentage of hemor- 
rhage cases was 81 ; while Leube's percentage was 46 ; 
and these writers present the following striking table 
for comparison : — 




Mass. Gen. Hospital 



Mortality . 

Hemorrhage 

Perforation 



8.0 per cent 
3.7 per cent 
2.7 per cent 



Now, of Greenough and Joslin's one hundred and 
eighty-seven cases, 80 per cent were recorded as cured 
at the time of their discharge from the hospital; but 
the striking and important fact is that on later investi- 
gation 40 per cent only were found to be well. Of 
ninety-nine patients who left the hospital, eight subse- 
quently died 1 of gastric diseases ; and forty-one had a 
recurrence of ulcer symptoms. So they note this fact 
that recurrence took place in one-half of the cases ; 
twelve of this number, however, reported themselves 
well at the time of writing. The authors make this 
interesting comment, " It certainly is startling to realize 
that every other patient with gastric ulcer is either to 
have a recurrence of symptoms, or is never to be well 
again." 

Among the conclusions of Greenough and Joslin let 

1 Seven other patients died after leaving the hospital : in three of them 
the cause was known to be other than gastric; in four it was in doubt. 



138 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

us note the following as bearing particularly upon the 
subject under consideration : — 

Gastric ulcer is five times as common among women 
as among men. 

The average age of the male patients is thirty-seven 
years ; of the female patients, twenty-seven years. 

Hemorrhage was present in 81 per cent of these cases. 
It caused the death of 17 per cent of the male patients, 
but only 1.27 per cent of the females. No woman under 
thirty died of hemorrhage from gastric ulcer during this 
period. 

Perforation occurred in 3.2 per cent of the cases, and 
none of these patients left the hospital alive. 

Of the one hundred and fourteen patients traced, 
80 per cent were discharged cured and relieved ; but at 
the end of an average period of five years, only 40 per 
cent remained well. The mortality at the same time 
(due to gastric disease) was 20 per cent. Among the 
males it was 30 per cent, among the females 9 per cent. 

The excessive mortality of ulcers among men, its 
occurrence in life a decade later than among women, 
and the absence of fatal cases of hemorrhage among 
women points to a difference of the ulcers in the two 
sexes (men, chronic ; women, acute). 

The immediate mortality of 8 per cent, and the fail- 
ure of medical treatment to effect a lasting cure in 
60 per cent of the patients, indicates the need of more 
frequent surgical intervention in other than emergency 
cases of this disease. 



CHAPTER VI 

OPERATIVE TREATMENT OF NON-MALIGNANT DISEASES 
OF THE STOMACH 

The operative treatment for non-malignant diseases 
of the stomach and duodenum offers perhaps the most 
important problem now before the surgical world, — a 
problem because not entirely solved, though a great 
advance toward its solution has been made. The duo- 
denum, or more properly, that portion of the duodenum 
above the opening of the common bile-duct, — the ves- 
tibule of the intestines, as W. J. Mayo calls it, — must 
be considered together with the stomach, for it is sub- 
ject to much the same chemical influences, and is the 
seat of similar disturbances. 

These non-malignant lesions result from inflamma- 
tions, either actually present or remotely causative. 

Ulcer is the common offender, and we have seen how 
frequent that is : ulcer, single or multiple, healed or 
unhealed, causing hemorrhage, cicatrices, distortions, 
stenosis, adhesions, dilatation, ptosis, involvement of 
neighboring organs ; ulcer resulting in permanent ill 
health and often terminating in cancer. 

In this chapter we choose to review the whole subject 
of those stomach operations which do not deal with 
malignant disease. Have not these operations for their 
purpose the relief of symptoms depending on ulcer? 
Authors have been in the habit of writing on the treat- 
ment of hemorrhage, perforation, ulcer, hour-glass stomach, 

139 



140 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

adhesions, and a variety of other conditions, as though 
such things were in themselves individual entities, — 
and they have so written, often greatly to the confusion 
of the reader. In order intelligently to discuss the 
subject of stomach surgery, one has to bear in mind 
the constant correlation of those conditions, and the 
dependence of them all upon ulcer. We shall deal 
severally with these various manifestations of ulcer, in 
the development of our theme, but we shall endeavor 
to do so while striving not to befog the reader's mind 
with a multitude of side issues. 

If the preceding chapters have made their point, 
they have shown that in a considerable proportion of 
stomach cases relief must be sought through operation; 
but we are as yet far from asserting that the indica- 
tions for operation are always clear. That is the diffi- 
culty of the situation, at present. In that our position 
is different from the firm ground on which we stand 
when dealing with appendicitis. All men now admit 
that appendicitis is a " surgical disease." In reaching 
that conclusion we passed through fire. So, too, with 
the question of operations on the bile passages. Every 
well-informed practitioner now turns to the thought of 
surgery when he is confronted with a case of gall-stones. 
We believe firmly that chronic gastric disorders should 
be subject to surgical consideration equally with chole- 
lithiasis, and we anticipate that the time is not far 
distant when such will be the case, and by surgical 
consideration we do not necessarily mean operation. 

When one consults the great volume of literature deal- 
ing with the surgery of gastric disease, and reflects on the 
immense amount of good work — no longer pioneer work 



OPERATIVE TREATMENT 111 

— already done, and regards the conclusions reached by 
thoughtful surgeons who have concerned themselves 
with the matter, one cannot but wonder at the reluc- 
tance, amounting often to blindness, of those practi- 
tioners who allow their patients afflicted with " chronic 
dyspepsia" to drag along in the old way. Happily, 
physicians and surgeons are now meeting on common 
ground, thanks to candor on the one side and much 
insistence on the other. 

In certain respects it is peculiarly difficult, or impos- 
sible, to reach definite statistical conclusions regarding 
the problems of gastric surgery. The field is too re- 
cently tilled to permit of a long retrospect. Few end- 
results have been recorded ; but clinical observations of 
cases have been so numerous, so remarkable often, and 
so convincing, that they form a strong chain of sugges- 
tive though circumstantial evidence. The opinions of 
such men as Kocher, v. Eiselsberg, v. Mikulicz, Hart- 
mann, Robson, the Mayos, Bevan, Rodman, Fowler, 
Murphy, Munro, Deaver, and a host of others, call for 
the gravest consideration. Says Kocher : * — 

" The majority of practitioners do not sufficiently 
realize what brilliant results are to be obtained by 
operative means in chronic affections of the stomach, 
commonly known as gastric catarrh. 

"Not only can the numerous dangers of ulcerating 
affections of the stomach, such as hemorrhage, perfora- 
tion, transition into cancer, be prevented, but the disease 
and its results may be so rapidly and certainly cured 
that the medical treatment of obstinate cases must be 
put in the background. . . . 

1 " Text-book of Operative Surgery," 1903, English edition, p. 199. 



142 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

" The pain in the stomach disappears immediately- 
after the operation. This is the invariable rule. . . . 
The patient does not require to pay any further atten- 
tion to the nature of his food. 

" The vomiting disappears. 

" The bowels become regular. 

" Repeated investigation of the gastric contents shows 
that there is a progressive improvement in the process 
of digestion ; hyperacidity diminishes ; if too little acid is 
present, it becomes increased [italics ours], a statement 
which is in agreement with Stendel, Carle, and Fantino, 
Kautsch, Hartmann, Soupault, and Mintz. 

"The flow of bile into the stomach . . . has no 
deleterious influence either on the health of the patient 
or on the function of the stomach. 1 . . . Operative 
treatment of the results of ulceration is the true cure for 
this frequent and serious disease." 

Gilbert Barling writes : 2 " In simple, uncomplicated 
stricture of the pylorus or some other part of the stom- 
ach (hour-glass contraction) the relief has been almost 
complete and thoroughly gratifying ; the more severe 
the symptoms the more marked the benefit. If, as is 
not rarely the case (an important proviso), the patient 
has been markedly neurasthenic, the full benefit of the 
operation has been somewhat delayed, and subsequently, 
under stress of work or anxiety, a threatening of the 
old symptoms of pain and vomiting has arisen, due 
to gastric catarrh or to an easily exhausted nervous 
apparatus. With appropriate treatment these threaten- 
ings have passed off and the former condition of im- 

1 With this view Hartmann and Soupault agree. 

2 Lancet, May 10, 1904. 



OPERATIVE TREATMENT 143 

provement has been maintained." And even three years 
ago Barker * could say of seven cases of non-malignant 
pyloric stenosis, operated upon by posterior gastro- 
enterostomy, that all recovered, " and the change in 
health in those who had time to show it is most 
remarkable." 

John Rogers, Jr., 2 reporting five cases of gastric sur- 
gery, says : " In these five cases there was one death 
three weeks after operation, from an ascending infection 
of the urinary tract. But in none of them was there 
anything but satisfaction in the entire relief of symp- 
toms. As they represented respectively cancer, dilated 
or atonic stomach, ulcer, chronic gastritis [and ulcer ?] 
with hepatic cirrhosis, and benign stenosis of the pylo- 
rus, they can be said to be examples of successful treat- 
ment of nearly all kinds of chronic gastric disorders." 

Here are some rather ancient notes of Hartmann ; s 
he remarks that in gastric cases treated primarily by 
himself and his colleagues, the mortality was 2 per 
cent ; while of those cases treated medically by other 
physicians and referred late to him, the mortality was 
24 per cent. These notes are founded on an experience 
of sixty cases. He goes on to tell of the end-results in 
twenty -nine cases followed for from one to four years : — 

Pylorectomy, one ; well after eighteen months. 

Gastropexy, one ; well after two years. 

Gastroenterostomies, eighteen ; well after two years, 
sixteen, while two were markedly relieved. 

Eleven cases of the writer were operated upon during 
the past year, eight by Finney's method for pyloric 

l Ibid., Aug. 23, 1902. 2 Annals of Surgery, April, 1904. 

s Gazette Medicate de Paris, Nov. 15, 1902. 



144 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

stenosis, and three by gastroenterostomy for ulcer. The 
time elapsed is short, but all the patients protest they 
feel well and can eat and digest normally. 

Such evidence as is quoted above is neither final nor 
convincing. It is introduced here merely to show what 
is the feeling of surgeons regarding the outlook in this 
field. Some statistics and details will be considered 
later in this chapter. 

As to the effect of these operations on stomach func- 
tion, we have some information. Kocher's experience 
has been quoted. 

In Hartmann's " Travaux de Chirurgie " for 1903, his 
colleague, Maurice Soupault, published some interesting 
observations on ten cases studied before and after 
gastro-enterostomy. 

He found that there is no definite rule as to post- 
operative hypersecretion and hyperacidity in the fasting 
as compared with the digesting stomach, and he dis- 
cusses three groups of cases illustrating these conditions. 
His conclusions are worth quoting : — 

" Why are these differences ? Several explanations 
may be given. 

" First the reflux of bile and alkaline intestinal juices, 
when copious, may neutralize the gastric acidity in 
varying proportions according to their intensity. 

" Second, the gastric evacuations through the new 
opening may take place more or less rapidly, according 
to the position and caliber of the anastomotic orifice. 
It is easy to conceive that the gastric secretions may be 
influenced in this manner. 

"Third, the position and extent of the ulcer — the 
primary and necessary cause of the gastric hypersecre- 



OPERATIVE TREATMENT 145 

tion — appear to us also to be very important. We 
believe that the gastric juice is the result of a reflex, 
the point of departure of which is the irritation of the 
ulcer ; and we believe that this reflex is the more con- 
siderable according as the lesion is more important and 
is situated in a less tolerant region. 

" After the gastroenterostomy it is probable that, at 
times, the ulcer remains isolated from the gastric con- 
tents and ceases to be irritated by such contact. 

" In other cases it continues to be bathed, at least in 
part, by the liquids capable of irritating it, although to a 
less degree than before operation. One of the principal 
reasons which induces us to admit this theory ... is 
that in patients upon whom a resection of the ulcer 
has been done the gastric chemistry has undergone im- 
portant modifications, but very different from those 
modifications occurring after simple gastroenteros- 
tomy." 

With such reflections and considerations in mind, and 
admitting that certain cases demand operation, the sur- 
geon asks himself and endeavors to answer the follow- 
ing two vital questions : — 

When shall we operate ? 

What method shall we employ ? 

In order to answer these two questions, when and how, 
remember that chronic disease only, as a rule, demands 
surgical intervention. There are exceptions, for have 
we not already emphasized the necessity of operating 
in the case of acute perforating ulcer? It is chronic 
disease, however, that we shall consider here, — and 
some of the chronic conditions which we find calling for 
operation are : — 



146 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

1. Ulcer. 

2. Pyloric stenosis with gastrectasis. 

3. Hemorrhage. 

4. Distortion of the stomach (hour-glass). 

5. Adhesions. 

6. Multiple erosions. 

7. Tetany. 

8. Gastric cirrhosis. 

9. Spasm of pylorus (Reichmann's disease). 
10. Ptosis. 

Several of these conditions are so frequently asso- 
ciated with each other, are so interdependent, and 
involve so often disease of other organs, that the in- 
ternist and the surgeon constantly must be considering 
the possibility of such complications and be prepared 
even for difficult and extensive secondary operations. 

Chronic Ulcer. — If chronic ulcer were a simple affair, 
confined to a localized area in the gastric mucosa, if 
it were single and uncomplicated, it would call for 
no special consideration in this book. Such an ulcer, 
if detected, could be cured by the measures of the in- 
ternist, — by rest and careful feeding. But commonly 
chronic ulcer is a complicated affair, and it calls for 
the surgeon's intervention because it is complicated. 

Its complications may be grouped under two head- 
ings : — 

(a) Those which are induced by the active spread 
of the ulcer itself, — hyperchlorhydria, pyloric spasm, 
hemorrhage. 

(5) Those which result from the ulcer's passive ten- 
dency to heal, — the complicating cicatrices, stenosis, 
distortions, adhesions, and the like. 



OPERATIVE TREATMENT 147 

So, commonly, the surgical writer, when he comes to 
the question of indications for operations on the 
stomach, is wont to seize upon certain consequences of 
gastric ulcer and explain that he operates for their 
relief; he operates on account of hemorrhage, distor 
tions, tetany, etc. 

This manner of writing is sometimes the result of 
inaccurate thinking and has led to constant confusion 
among readers, as well as to an almost hopeless chaos 
for the student when he attempts to unravel and 
classify statistics. For instance, those useful publica- 
tions of Moynihan 1 and Joslin, Lund and Murphy, 2 
purport to deal with definite groups of cases, which 
the writers pigeonhole under such titles as " Hem- 
orrhage," " Chronic Ulcer," " Hour-glass Stomach," 
" Pyloric Obstruction," and the like. One can make 
no sharp distinctions in writing up the records, for hem- 
orrhage may be associated with pyloric obstruction, 
and hour-glass stomach with both, while all three are 
part of the process of chronic ulcer. 

Moreover, chronic ulcer itself may be mistaken for 
malignant disease even at operation, so that further 
confusion is thus introduced into the records. 

Bearing in mind, then, that hemorrhage, adhesions, 
and gastrectasis are merely evidence of ulcer, and rec- 
ognizing conversely that ulcer — active, latent, or cica- 
trized — is concerned with most of the non-malignant 
conditions for which we operate, let us take up these 
conditions severally and study our methods of treating 
them. 

1 " Surgical Treatment of Gastric and Duodenal Ulcers," 1903. 

2 Boston Medical and Surgical Journal, Aug. 4, 1904. 



148 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Pyloric Stenosis with Gastrectasis. — Certain aspects of 
this condition have been dealt with in our Chapter IV, 
and the fact has been pointed out that the vast ma- 
jority of persons with dilated stomachs die shortly or 
remain chronic invalids. Of those persons who sur- 
vive, the exact nature of their pyloric obstruction 
cannot always definitely be asserted ; but since in this 
chapter we exclude cancer as a cause of the presumable 
obstruction, we can state that we are dealing here with 
a cicatricial stenosis from ulcer, with a high pylorus 
kinked by a short gastro-hepatic ligament, with a gas- 
troptosis, or we are dealing with all three. Sometimes, 
too, there is the thickened non-malignant pylorus, in 
which no ulcer scar is found. Stenosis from ulcer, 
either healed or unhealed, is probably the commonest 
of these causes of dilatation ; and in the sequence of 
events leading up to the symptoms we find established 
first an initial inflammatory condition, then a failure of 
proper drainage for the products of inflammation, then 
the superadded and inevitable presence of the normal 
secretions undrained, and finally of food undrained. 

These conditions, by increasing the total amount to 
be drained, diminish the expulsive powers of the stom- 
ach, weaken its walls, and cause dilatation, with in- 
creased stasis. Furthermore, actual tissue changes 
going on at the same time, usually at the pyloric end of 
the stomach, result frequently in true organic stricture, 
through cicatricial contraction, — the attempt of nature 
to heal. Even if there be no organic stricture, a dilated 
stomach may sag and cause a kinking at the pylorus, — 
a kinking which may obstruct the outlet. 

If this contracting process has not gone too far, lavage 



OPERATIVE TREATMENT 149 

and dieting may relieve the symptoms when there is no 
cicatrix closing the stomach's outlet ; but often, when 
the patient with such symptoms presents himself, it is 
too late for any mild treatment. There is no resource 
save operation. 

Stomach drainage is the operation indicated and it is 
imperative, — drainage from the stomach into the intes- 
tines. Methods of securing such drainage will be de- 
scribed shortly. The remote good results of operative 
treatment have been indicated already. What are the 
dangers attending the operation ? 

That is a question about which there has been the 
gravest discussion, and popular opinion in the profession 
is undetermined still. Surgical opinion is now fairly 
definite, however, and this divergence of estimates — 
the popular and the surgical — is due to lack of imme- 
diate knowledge on the part of medical practitioners. 
One cannot draw conclusions from the statistics of three 
or five years ago. Save for a few exceptional clinics, 
the work being done a few years ago was bad, from our 
present viewpoint. Experience in operating was small 
and technique was imperfect. Operations on the stom- 
ach and intestines are particularly careful work. They 
differ from ordinary surgery as much as the work of the 
woodsman differs from that of the tailor. In general 
terms routine operations on most parts of the body 
imply destruction. Stomach surgery implies construc- 
tion. The hasty operator should have no part in such 
tasks. It requires a peculiarity of temperament, a 
nicety of touch, an exquisite care of detail, successfully 
to perform a pylorectomy, a gastro-enterostomy, or the 
operation of Finney, such as was not always acquired 



150 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

by general surgeons a few years ago. Gradually and of 
late some few operators have perfected themselves in it, 
and to such men we owe it that in the past two years 
the mortality of these operations has fallen rapidly and 
is still falling ; while from a comparison of experiences, 
old and new, and immediate results we are coming to 
perceive with added assurance that our end-results are 
to be increasingly good. 

A further and important reason for our growing 
optimism is that we are treating to-day a less uni- 
formly difficult class of cases than was brought to us a 
few years ago. A competent surgeon in dealing with a 
simple uncomplicated pyloric stenosis, not far advanced, 
in a patient still in fair health, should expect a cure. 
Even three years ago we had to do with patients ex- 
hausted by long illnesses, the victims of complicated 
and extensive lesions often impossible of mechanical 
improvement. Such patients came to us as a last 
resort ; often they failed to leave the hospital alive ; 
often our operations proved merely palliative or ineffec- 
tual. With such material to work upon, and against 
the proper conservative criticism of the profession, sur- 
geons have been demonstrating their proposition that 
these disabilities are mechanical and demand mechanical 
remedies. 

Gradually, we believe, the burden of proof has been 
shifted. Not long ago the internist said, Show us that 
these operations are essential, safe, and curative, and 
you shall have our patients. While now, in view of our 
growing array of facts and good work accomplished, the 
surgeon says, Show us reason for withholding from these 
patients the benefits of operation. 



OPERATIVE TREATMENT 151 

In the light of what we have said, then, let us examine 
a few figures, old and new, but with this proviso: 
there are no figures given that deal with simple obstruc- 
tion dependent on ulcer no longer active. Ulcers are 
often multiple. Thinking no ulcer is present, one may 
operate for a stenosis when an undetected ulcer is there, 
either at the pylorus or elsewhere in the stomach. 

Robson and Moynihan in their book on diseases of 
the stomach, edition of 1904, state of drainage opera- 
tions that in the years 1881 to 1885 the mortality was 
65.71 per cent ; 1886 to 1890 the mortality was 47 per 
cent ; 1891 to 1896 the mortality was 33.91 per cent, 
among all operators reporting all manner of cases. The 
Mayos 1 in 1902 reported eighty -nine gastrojejunostomies 
in uncomplicated cases, with a mortality of 7.8 per cent ; 
and 28 gastro-duodenostomies by Finney's method, with 
a mortality of 3.5 per cent. While Robson and Moyni- 
han are able to state that of their last two hundred and 
eighteen operations for non-malignant disease the mor- 
tality was but 3.2 per cent. 

In 1904 Finney reported to us by personal letter that 
in his own experience with the operation which goes by 
his name there were fifteen cases with one death, a 
mortality of 6.6 per cent. 

In this same year of 1904 there were reported from 
Boston hospital records by Lund, Joslin, and Murphy a 
series of cases of pyloric obstruction, running over the 
five preceding years ; twenty-one cases with five deaths, 
a mortality of 23.8 per cent. Even of those who recov- 
ered, four were not relieved and two came to secondary 
operations. But it is obvious in a study of the cases 

1 Annals of Surgery, June, 1903. 



152 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

and with our present knowledge, that the technique of 
many of the operations was grievously at fault, nor are 
complicating conditions taken into account. 

Of the older operations, Bevan says : 1 " An analysis of 
the cases demonstrates that here again gastroenteros- 
tomy has won for itself the position of the operation 
of choice. It has supplanted Loretta's divulsion, the 
Heineke-Mikulicz pyloroplasty and pylorectomy. . . . 
The Heineke-Mikulicz pyloroplasty has been largely dis- 
carded because, in a considerable per cent of the cases, 
recurrence follows the rather brief relief of symptoms." 

As one tries to sift out from the literature those cases 
in which pyloric stenosis is the important feature, one 
finds such figures as the following : — 

In 1903 Moynihan 2 reported thirty -seven cases with 
no deaths. No end-results were obtained in eight of 
the cases, but twenty-nine were reported as perfectly 
well. 

Robson and Moynihan reported further twenty-eight 
cases of obstruction operated upon, with four deaths. 
Twenty of the cases were found cured completely after 
from one to three years, while four were not heard 
from. An analysis of the cases shows that the four 
patients who died were extremely ill at the time of the 
operations. 

Surprisingly interesting is a paper published in 1904 
by Munro, 3 who reported in the most candid and cour- 
ageous fashion a large series of cases with a high 
mortality. From a careful reading of his thoroughly 

1 Journal American Medical Association, Jan. 24, 1903. 

2 «« The Surgical Treatment of Gastric and Duodenal Ulcers." 
8 Boston Medical and Surgical Journal, Aug. 11, 1901. 



OPERATIVE TREATMENT 



153 



described work it is immediately obvious that he was 
dealing largely with desperately sick people, most of 
them sent to him as a last resort. Twenty-three of 
these operations were performed for non-malignant 
stenosis. Five patients died. Owing to the short 
lapse of time since the operations, he is able to show 
but five end-results. The remaining thirteen patients 
left the hospital well, however. In passing, one ob- 
serves that five of Munro's cases were operated on by 
Finney's method, with a mortality of zero. 

So we have recorded in this section the reports of 
a few men. Note the reports summarized in the fol- 
lowing table; at the same time observe that the most 
unfavorable figures — those of the Boston hospitals, col- 
lected by Lund, Joslin, and Murphy — cover five years 
— pioneer years — and end with 1903 ; while Munro 
dealt with an unfavorable class of cases which he had 
the hardihood to report without excuse, save the 
graphic case-histories : — 

RESULTS OF OPERATION FOR PYLORIC STENOSIS 

167 Cases Collected from Sundry Clinics 





Operator 


No 
Cases 


Immediate Results 


End-results 


Mortality 




Good 


Bad 


Good 


Bad 


1902 
1903 
1903 
1903 


Barling 

Mayo .... 

Moynihan . 

Lund, Joslin, and 


7 
28 
37 


7 

27 
37 



1 



7 
27 
29 




1 

8(?) 




3.5% 



1904 


Murphy collection . 
Robson and Moynihan 


21 
28 


12 
24 


4 
4 


9 
20 


7 
8 


23.8% 
14.3% 


1904 


Munro 


23 


18 


5 


5+ 


? 


21.7% 


1904 
1904 


Finney 
Mumford . 


15 

8 


14 
8 


1 




14 

8 


1 



6.6% 





167 


147 


15 


119+ 


25± 


8.9% 



154 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

We hope we do not insult the intelligence of the 
reader by observing it would be fatuous to suppose 
that this small collection of figures gives a fair estimate 
of the work now being done by all the surgeons quoted. 
Nor do we fail to recognize that one hundred and sixty- 
seven cases is a very small fraction in this field of 
work ; but we are seeking end-results, and, at this 
writing, end-results have not been extensively reported. 
Those given are what we could obtain after a search 
of the most recent literature and some personal corre- 
spondence. 

Fragmentary as the table is, it certainly bears out 
our contention that these operations are not especially 
dangerous, and that the end secured is good ; while we 
have shown previously that without operation the great 
majority of such cases must look forward to lives of 
invalidism and to early death. 

Hemorrhage. — There is the bleeding from acute ulcer, 
and there is the bleeding from chronic ulcer, the writers 
will tell you. But the affair is not so simple as that. 
Who is to say, always, what is acute ulcer, and what 
is chronic ? There is the acute hemorrhage from chronic 
ulcer, which is sometimes spoken of as " acute bleeding 
ulcer." 1 It is well to bear in mind the following dis- 
tinguishing facts : In acute ulcer, perforation is to be 
dreaded, in chronic ulcer, hemorrhage. While hemor- 
rhage is sometimes alarming in acute ulcer, one need 
look for no permanent ill effects from it. There's the 
rub. For the hemorrhage may not be from an acute 
ulcer at all, but from a chronic ulcer, long unsuspected. 

1 See argument founded on this misapprehension, Boston Medical and 
Surgical Journal, Vol. CLI, p. 259, 1904. 



OPERATIVE TREATMENT 155 

However, for the sake of clinical convenience, we 
may say that the hemorrhage is from an acute ulcer 
when that hemorrhage is our first intimation that an 
ulcer is present. Such acute ulcer hemorrhage is venous 
usually. It may be profuse ; it is nearly always tran- 
sient. Do not operate for its relief. Under rest and 
dieting the bleeding will not recur and the ulcer will 
probably heal. 

There are acute hemorrhages, however, which are far 
more serious matters, acute hemorrhages from chronic 
ulcers. Observe the types of hemorrhage from chronic 
ulcer. They depend on the progress of the ulcer and 
its seat : — 

(V) Frequent slight hemorrhage, — venous or capillary 
oozing, — sapping vitality, leading to profound anaemia, 
often undetected for long, a very serious matter. For 
such bleeding you must operate and with assured hope 
of cure. 

(5) Intermittent hemorrhage, of considerable quan- 
tity, probably from a small eroded artery. This never 
ends with fatal bleeding, but the patient is apt to 
become profoundly depressed. Gastroenterostomy for 
drainage is here indicated. The bleeding ceases, and 
the ulcer, no longer irritated, gradually heals. 

(c) Acute and profuse hemorrhage associated with 
pronounced gastric symptoms, — pain, vomiting, — soon 
repeated. Such profuse hemorrhage may kill. 

A fourth variety of hemorrhage is talked about, 
though, indeed, it is but an exaggeration of type (<?). 
Moynihan describes it thus : — 

(d) " The hemorrhage is instant, overwhelming, 
lethal." 



156 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

In the case of pronounced and recurring dangerous 
hemorrhage, gastro-enterostomy must be our sheet 
anchor. If we can so operate in an interval between 
bleedings, we may look for a cure. Do not explore 
the stomach and seek to excise the ulcer. Gastro- 
enterostomy is enough. 

On the other hand, any operation performed upon the 
stomach during or immediately after a severe and ex- 
hausting hemorrhage is very likely to prove fatal. 

When we reflect that about 8 per cent of all gas- 
tric ulcer cases end in death from hemorrhage, by so 
much is force added to the surgeon's urgent advice that 
all such ulcers which do not yield promptly to the 
internist's treatment should be treated by gastro- 
enterostomy. 

The writers have found it impossible to collect a 
large array of figures illustrating the results of opera- 
tions for hemorrhage ; moreover, the few authorities to 
be quoted use the term " hemorrhage " in various senses. 
From a careful reading of the cases of Robson and 
Moynihan it is obvious that when they perform a stomach 
operation upon a patient who has recently had haema- 
temesis or melena, they list the operation as done for 
hemorrhage. Accordingly, their results are good when 
they operate for hemorrhage, for they operate properly 
in the interval. On the other hand, Munro and the 
reporters for the Boston hospitals mean by hemorrhage 
active present bleeding, or bleeding but just ceased. 
So their reported results are bad. Scattered reports 
from numerous surgeons teach conclusively the lesson 
that emergency operations to check violent gastric 
hemorrhage almost always end disastrously. 



OPERATIVE TREATMENT 157 

In this connection it is interesting to point out to our 
confreres, not surgeons, that individuals who control 
great clinics — such men as are Robson in England, 
v. Mikulicz in Germany, Kocher and Roux in Switzer- 
land, the brothers Mayo in America, and a few such 
others — have opportunities for seeing cases early, for 
following them, and for electing the time for operation, 
— such opportunities as, up to the present, have not 
been vouchsafed to the great majority of operators. 

If a surgeon sees his case for the first time, when the 
patient is blanched and prostrated with recent hemor- 
rhage, and an operation is urged by the internist as a 
last life-saving measure, it is obvious that a grievous 
responsibility is laid upon the operator, who enters upon 
his task with the almost certain knowledge that his 
endeavors will prove futile. 

Consider the following statements : — 

1. Robson and Moynihan, in 1901, reported twelve 
cases of hemorrhage from ulcer operated upon by gastro- 
enterostomy. Eleven recovered and one died, — a mor- 
tality of 8.3 per cent. 

2. Rodman, in 1902, collected thirteen similar cases ; 
three died, — a mortality of 23 per cent. 

3. Moynihan, in 1903, published other twelve cases, 
of which one died, and that one not subjected to gastro- 
enterostomy, but to excision of the ulcer, — a mortality 
of 8.3 per cent. 

A careful review of the twenty-four cases of the Eng- 
lish surgeons, cases serious and more or less complicated, 
demonstrates that mostly they were not urgent, but were 
proper operative risks. 

On the other hand, Munro, in 1904, reported faithfully 



158 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

his eight desperate cases. Seven died and one recovered, 
— a mortality of 87.5 per cent, while Lund, Joslin, and 
Murphy, in 1904, presented us with report of ten cases 
gleaned in five years from the Boston City and Massa- 
chusetts General hospitals, — ten cases with a mortality 
of 100 per cent. 

Such facts call for no further explanation. The last 
compilers remark tersely, " Surgical intervention in gas- 
tric hemorrhage should be considered even before it is 
urgent, and the surgeon should jointly with the physician 
watch the course of the patient." 

In other words, simple drainage operations done for 
bleeding gastric ulcer, but done when the patient is in 
fair condition, usually will result in cure. 

Surgical opinion has become nearly unanimous that 
in almost all such cases the operation of choice is gastro- 
enterostomy. Excision of the ulcer, infolding of the 
ulcer, or attempts to tie the vessel are unsatisfactory 
procedures, for the ulcers may be multiple, the process 
may not be checked, and the vessels may not be found. 
Gastro-enterostomy in itself shows a low mortality, and 
it generally cures the underlying process. 

Distortion of the Stomach. — We prefer this phrase to 
"hour-glass stomach." The latter term is sanctioned 
by usage, but it is frequently inappropriate and repre- 
sents only a fraction of the stomach deformities caused 
by advanced ulcer. In Chapter V we had some words 
to say of the nature of hour-glass stomach ; and what 
we said there applies practically to most distortions of 
the stomach which tie it up or locally constrict its cali- 
ber, and so diminish its motility. 

Of course, the purpose of surgery — for here, obviously, 



OPERATIVE TREATMENT 159 

medicine will not avail — is to free the stomach from 
crippling adhesions and to restore its lumen approxi- 
mately to the normal. Fortunately, this can be done 
(1) by fairly simple operative measures, in which 
the isolated gastric pockets may be brought together 
and an anastomosis made between them. The result 
is not a stomach reconstructed on normal lines, but 
a series of freely communicating and easily draining 
pouches. 

Our personal choice is (2) a gastro-plasty, when pos- 
sible, done after the manner of Finney's gastro-pyloro- 
duodenostomy. In the one case, operated upon in 
April, 1904, in which we have used this method, the 
result was satisfactory anatomically and symptomati- 
cally. 

(3) Gastro-enterostomy is a poor substitute for the 
two previous operations unless one is dealing with a 
coincident pyloric stenosis or with active ulcer. Anas- 
tomoses should be made between the jejunum and each 
individual stomach pocket. 

Partial gastrectomy should be our resort only in case 
of such extensive crippling and distortion of the stomach 
as render impossible the other operations. 

A careful reading of the recent surgical literature 
shows that these operations for distortion are somewhat 
more hazardous than are those for uncomplicated pyloric 
stenosis. Obviously this must be so, for distortions of 
the stomach imply long-standing disease and frequent 
complications. One may find more or less extensive 
adhesions and involvement even of other organs in the 
inflammatory process. 

Scattered through the journals there are to be found 



160 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

reports of cases of stomach distortion, but there are few 
groups of statistics. In 1901 Robson and Moynihan col- 
lected all the cases which had been reported up to that 
time. We give them in the following table, together 
with three cases reported by the Mayos and thirty-four 
reported personally by Robson and Moynihan : — 

OPERATIONS FOR DISTORTIONS OF THE STOMACH 

(Hour-glass Constriction) 







Cases 


Immediate Kesults 


End-results 


Mortality 




Good 


Bad 


Good 


Bad 


1889- 

1901 

1901 

1903 

1903 


All cases 

Robson and Moynihan 
Mayos .... 
Moynihan . 


33 

18 

3 

16 


23 

17 

2 

13 


10 
1 
1 
3 


21 
17 

2 
13 


2 





30.3% 

5.5% 

33.3% 

18.7% 






70 


55 


15 


53 


2 


21.4% 



These are figures which do not represent the work of 
one man, or one group of men. Twenty-five operators 
contributed the statistics, and even so the total mortality 
cannot be called excessive. As is the case with other 
types of operations which we have studied, clinical ex- 
perience is showing that we are constantly improving 
over such printed reports as are given in the above table, 
and it is a striking fact that a majority of the patients 
who recovered are stated to have remained well, — fifty- 
three out of fifty-five immediate recoveries. 

Adhesions. — Perigastric adhesions form probably the 
most common complications or results of gastric ulcer. 
Fenwick states that adhesions are found at autopsy in 
42.5 per cent, or nearly half of the ulcer cases. In those 



OPERATIVE TREATMENT 161 

cases which come to post mortem this is doubtless true, 
but we do not believe it is true of all cases of gastric 
ulcer. However that may be, the condition is common, 
and merits the earnest consideration of internist and 
surgeon. 

Of all the complications of ulcer, adhesions are per- 
haps the most difficult to make out before abdominal 
exploration ; yet the condition often is extremely dis- 
tressing and serious. The patient will tell of indefinite 
discomfort, eructations, pain, distress ; but the symp- 
toms vary according to the seat and extent of the ad- 
hesions. If the adhesions are near the pylorus, one 
observes all the indications of a pyloric stenosis ; if they 
are in the fundus, one may have to deal with an actual 
hour-glass constriction and its accompanying symptoms ; 
if they are near the cardia, one may see difficulty in 
swallowing, vomiting soon after eating, and great mal- 
nutrition ; while in all cases adhesions may affect 
neighboring organs and cripple their functions. 

In the case of adhesions it is not to be expected that 
anything short of a successful operation will bring last- 
ing relief, especially as the conditions are frequently 
associated with other permanent lesions within the 
stomach itself. If the adhesions admit of a simple 
gastrolysis, or separation of surfaces, the patient is 
fortunate. When the conditions demand no more than 
that, a cure often is established. 

There is the danger of the re-formation of adhesions, 
though this does not necessarily always follow, nor do 
fresh adhesions always bring back with them the old 
symptoms. If the separated raw surfaces are exten- 
sive, and if recurrence is dreaded, the surgeon may 



162 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

interpose, to advantage, Cargile's membrane or omental 
grafts. 

From the operator's point of view the most serious 
adhesions are those which cannot be separated without 
extensive laceration of organs or the breaking down 
of flstulse already established. Such cases must be 
handled according to one's individual judgment. Often 
in such cases it will be thought wise to leave the ad- 
hesions undisturbed, and to attempt restoration of 
gastric function by some drainage operation, such as 
gastrojejunostomy. 

Erosions. — The absolute frequency of erosions is not 
ascertained, for they cannot be determined except by 
exploration of the stomach. Doubtless confusion arises 
frequently. Erosions may be taken for a bleeding 
chronic ulcer, when the evidence of hemorrhage with 
hyperchlorhydria and a certain amount of pain may 
mislead one as to the true condition. 

In most cases, if there be no stenosis, erosions will 
disappear under rest, dieting, and the use of bismuth in 
large quantities, — at least we must so assume if we can 
make the diagnosis. Certain of the cases of erosions 
persist, however, and may be cured by appropriate drain- 
age through gastro-enterostomy. Physicians ask, How 
long shall we wait before resorting to such surgery ? 
A year, unless the patient's failure is so rapid as to 
make radical measures imperative. 

From time to time surgeons report that they save 
cases of active hemorrhage by operating while bleeding 
is going on, — that they find a stomach half full of blood. 
Commonly, in such a case they are dealing with erosions, 
— quite a different matter from opening the stomach in 



OPERATIVE TREATMENT 163 

the case of acute arterial hemorrhage. Usually one will 
cure erosions by gastroenterostomy, while the victim 
of an actively bleeding vessel is likely to die. 

Gastric Tetany. — In every case of tetany one should 
think of the possibility of pyloric obstruction. In chil- 
dren we see convulsions associated with gastro-intestinal 
disturbances ; in adults organic stomach disease is one 
cause of tetany. It is only since Kussmaul's observa- 
tions, in 1869, that we have recognized a relation between 
gastric disease and tetany, but we are now coming to 
believe that gastric tetany is not so uncommon as was 
supposed. 

It is needless here to detail the symptoms, which run 
all the way from a numbness and tingling to spasms 
affecting many groups of muscles. The attack may end 
with death in coma. 

Usually gastric dilatation is the coincident causative 
condition in tetany, the spasms being due, probably, to 
the absorption of some poison from the dilated stomach, 
with an associated painful contraction of the pylorus. 

Obviously stomach lavage is indicated for relief, and 
sometimes lavage can be accomplished ; but unfortu- 
nately it has been found that attempts to pass the tube 
may bring on convulsions and closure of the pharynx, 
making the procedure impossible. 

So, under medical treatment, the disease has had a 
high mortality. Moynihan 1 refers to a collection of one 
hundred and one cases with a mortality of 64.35 per 
cent without operative treatment, and he points out the 
value of drainage by gastro-enterostomy as the only logi- 
cal resource. 

1 Boston Medical and Surgical Journal, Nov. 5, 1903. 



164 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Cunningham a relates in detail an important case in a 
young man of twenty-eight, who had been the victim of 
stomach disease for eight years. Refusing operation, he 
was observed from time to time at the Boston City Hos- 
pital for two years. He had several attacks of tetany, 
became greatly reduced, and finally, in wretched con- 
dition, was operated on as an emergency case by Wat- 
son. He recovered and five months later, at the time of 
the report, was well, stating, < ; I was never so well in 
my life." That case is an admirable illustration of gas- 
tric tetany, and the result of investigation of such con- 
ditions shows that they are always dangerous, with a 
high mortality under palliative treatment ; but that, 
given a fair chance, as in this instance, stomach drain- 
age cures. 

Gastric Cirrhosis. — This rare condition must be men- 
tioned merely in passing. Sheldon - has collected eleven 
reported cases and sums up in an interesting paper what 
is known of the subject. The disease is chronic, and 
does not appear to be associated with ulcer or cancer. 
The stomach wall is found thickened, often scarred and 
stenosed, and the symptoms resemble those of long-stand- 
ing ulcer, except that the vomiting is small in amount. 

Of the first ten cases collected by Sheldon, all died 
unrelieved. The eleventh, his own case, after years of 
invalidism and having suffered much at the hands of 
many physicians, was cured by Sheldon's gastroenteros- 
tomy. The rationale does not appear at once, but the 
success of the procedure seems undoubted. 

Spasr/i of the pylorus (Reichmann's disease), not 

1 John H. Cunningham. Jr.. Annals of Surgery, April, 1904. 

2 John G. Sheldon, Annals of Surgery, March, 1904. 



OPERATIVE TREATMENT 165 

associated with pathological changes, is a condition 
occasionally seen. It is said to be due to gastric 
hyperchlorhydria. but this is not always proven. 
Formerly Loreta's operation of stretching the pylorus 
was done for relief of the condition, until it was proved 
unsatisfactory. The symptoms are those of obstruc- 
tion. In such case again, if lavage, dieting, and far- 
adism fail to cure, gastric drainage is indicated : and 
we regard the pyloroplasty of Finney as the most 
rational procedure. 

Gastroptosis will be considered at length in a subse- 
quent chapter. Suffice it here to observe that prolapse 
of the stomach is common. Frequently seen in con- 
nection with ptu>es of other organs, it is seen especially 
associated witli gastric dilatation. Again, gastroptosis, 
by dragging on the fixed pylorus, may itself, through 
the resulting kinking of the pylorus, cause stenosis and 
gastrectasis. Beyer's operation of reefing the gastro- 
hepatic omentum has been found to correct the de- 
formity and relieve symptoms, while an independent 
or supplementary gastroenterostomy is also a useful 
procedure. 

We have ourselves, in a case of gastroptosis with dila- 
tation, practised Finney's pyloroplasty with resulting 
relief of symptoms. 

Such is a detail of some of the more common mani- 
festations of gastric ulcer for which the surgeon op- 
erates : let us ask ourselves, What conclusions may we 
draw from the work so far accomplished ? What are 
the patient's prospects ? Are we satisfied with our end- 
results ? What shall we answer the internist dealing 
with a case of obstinate chronic dyspepsia or pronounced 



166 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

ulcer when he asks how soon he is to seek surgical aid ? 
These are pertinent questions to-day. 

Briefly then : we believe that the problem is being 
solved rapidly, though the end is not yet. Chronic 
gastric ulcers, with their numerous sequelae, are being 
relieved and, it is hoped, cured by the surgeon. A con- 
siderable proportion are but little relieved, and a few die. 
Whether ulcer be the result of local necrosis, of trauma, 
of infection, or of an underlying systemic condition, 
the fact remains beyond peradventure that stomach 
drainage does put the ulcer at rest, does promote heal- 
ing, and does render improbable a recurrence of ulcer. 

Then our medical consultants will tell us, " All very 
true, but there are cases in which we have followed 
your advice, the operation has been done, and behold, 
the last condition is worse than the first." Here is an 
example of that very thing, with the explanation : — 

In the winter of 1903-4 a well-known internist 
studied a series of cases of impaired gastric motility ; 
he made up his mind that the symptoms present were 
due to a slight pyloric obstruction, without active ul- 
ceration, and he sent the patients to a local hospital 
for operation. His estimate of the conditions was 
verified. A few months later four of these cases, hav- 
ing been subjected to operation, again came under his 
care. All had a continuance of their old symptoms ; 
some were worse than before. But what operations 
were done ? we ask. Simple gastrojejunostomy with 
the long loop in all. 

No wonder the symptoms recurred. Under the 
conditions found, — a pylorus partly open, — what could 
have been more fatuous than such a simple gastro- 



OPERATIVE TREATMENT 167 

jejunostomy? The stomach was left with two openings; 
and when the new drainage was established through 
the anastomosis, the pyloric irritation subsided in part ; 
then all stomach contents passed the natural way ; the 
artificial opening closed, wholly or in part ; the original 
lesion gradually became reestablished, and the symp- 
toms recurred. We know now that this often is what 
happens. Simple gastroenterostomy in such cases is 
not the proper operation. The pyloroplasty of Finney 
would have resulted in cures ; so would gastroenter- 
ostomy with entero-enterostomy and section of the 
pylorus ; so would pylorectomy. To-day such a series 
of bad results as we have described would not occur in 
the clinic of a surgeon familiar with these operations. 

It is argued by sundry zealous surgeons, enthusiasts 
for this branch of work, that internists are too con- 
servative, are too critical, loath to abandon their own 
measures, sceptical of what surgery may accomplish. 
It is pointed out by such surgeons that an analogy with 
the present discussion is seen in the long dispute over 
appendicitis and over disease of the bile passages, — 
indeed, we ourselves may have seemed to use that argu- 
ment. Such statements on the part of surgeons are not 
entirely just. Progressive internists are no longer scep- 
tical, — indeed, some are almost too credulous. All of 
them are asking for light, for further information. In 
one respect, however, we believe that many general prac- 
titioners err. They call in the surgeon when they think 
an operation should be done. They should call him 
before that, — not to do the operation which they have 
decided upon, but to watch the case with them, to help 
in the decision as to the exact time and nature of the 



168 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

operation. That is where the analogy with appendicitis 
applies. The surgeon is consulted in every case of ap- 
pendicitis. Often he decides against operation ; but 
the responsibility is shared with the physician. In 
calling the surgeon the latter has discharged his duty. 

And with reference to gastric disorders ; if the case 
is obstinate, chronic, obscure, as soon as the physician 
has made up his mind that here is not a simple affair, 
easily remedied, but one in which surgery may some 
day have to intervene, then is the time for a consulta- 
tion. Thus will physician and surgeon alike advance 
their education. The time for operation may be after 
a day ; it may be after a month, Indeed, the ques- 
tion rarely is one of time alone. 

We admit that the analogy between stomach surgery 
and surgery of the bile passages is fairly enough drawn, 
— indeed, the two overlap and run into each other ; but 
between the appendix and the stomach, the comparison 
is not so obvious. Though sometimes difficult and call- 
ing for good judgment, surgery of the appendix is easy 
compared with gastric surgery. In the case of appendi- 
citis, the indications for operation are more certain and 
special procedures more definite. On this point we 
shall express an opinion. 

Such, in outline, is the situation as it appears to-day. 
We are aware that even as we go to press, new figures 
and more satisfactory statistics are being prepared ; but 
we hope we have said enough to show that progress is 
being made, and that the future of gastric surgery is 
important, broad, and promising. 

Some of the procedures and the technique of opera- 
tions upon the stomach will now be studied. 



OPERATIVE TREATMENT 169 

Gastric surgery is twenty-five years old, but for the 
first fifteen years its advance was halting and unsatis- 
factory. So long ago as 1880, von Mikulicz sutured a 
perforation on the lesser curvature of the stomach, but 
the patient died. In 1881 Rydygier excised successfully 
an ulcer. In that same year Wolfler devised and 
performed the first gastro-enterostomy. That was an 
anterior gastrojejunostomy, and was done for cancer. 
But it was not until 1893 that drainage operations for 
the relief of ulcer were introduced, and it is to Doyen 
that we owe this important advance. Since then the 
scope and value of these operations for all sorts of 
stomach derangements have developed rapidly, and a 
multitude of modifications have been introduced, some 
of the most important of which we propose to sketch. 

Preliminary treatment of the patient is dealt with at 
length by sundry writers, but in our opinion extensive 
treatment generally is needless in non-malignant cases. 
Unless the stomach be greatly dilated and foul, no more 
than one or two washings are called for. Careful anti- 
septic cleansing of the mouth and throat is important, 
as well as proper stimulation and support of the patient 
by nutrient enemata and other appropriate methods. 

After stomach operations, too, the excessive care in 
feeding practised a few years ago has been proved super- 
fluous. Water may be given as soon as the vomiting 
and nausea cease, and we find that the post-operative 
vomiting usually is not severe. Liquid food may be 
given after twenty-four hours, soft-solid food on the 
third day, and a moderate full diet at the end of a 
week, if all has gone well. 

It is advisable to keep the patients well propped up 



170 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

on pillows for the first week. Pressure upon the fresh 
lines of suture is thus relieved, and convalescence seems 
to progress more evenly and rapidly. 

We advocate more frequent and earlier exploratory 
operations. This is a familiar proposition to surgeons. 
Explorations used to be made as a last resort, to see if 
by chance something might not be done to remedy an 
almost hopeless condition, and generally nothing could 
be done. On the contrary, we should explore to make 
the diagnosis, not to confirm it, and we should then 
proceed in accordance with our findings. The old 
desperate exploration was for the most part useless, 
and often ended fatally. The proper modern explora- 
tion has a very low mortality. When nothing further 
can be done, W. J. Mayo wisely advises a quick sewing 
up, with buried silver sutures, of the short two-inch 
wound, and getting the patient out of bed in a week. 
The sutures hold and the patient usually avoids the 
danger of becoming bedridden. 

In general terms there are two methods commonly 
used for stomach drainage : posterior gastrojejunos- 
tomy, and anterior gastrojejunostomy, with their vari- 
ous modifications. Recent text-books on operative 
surgery describe in great detail these procedures, so 
that it does not seem in place for us to weary the 
reader with an elaborate dissertation on the subject. 
We shall rehearse the procedures briefly, however, 
describe among others three operations which we favor 
especially, and discuss methods of meeting particular 
conditions. 

I. When circumstances permit, we recommend the 
posterior gastrojejunostomy as advocated by Moynihan, 



OPERATIVE TREATMENT 171 

which, whether with or without the button, is also 
essentially that of Kocher, von Mikulicz, and Czerny, 
as detailed by Peterson. Scudder 1 has described this 
operation for American readers, and has done so in 
admirable, concise, and lucid fashion. We take the 
liberty of using his words in our account : — 

" The preliminary preparation of the patient, the iso- 
lation of the operative field, the selection of the place 
in the stomach and the intestine for the anastomosis, 
the use of rubber-covered clamps, the rapidity of suture 
without the use of needle holder, the employment of 
relatively large needles, the use of the Pagenstecher 
linen thread, the very careful attention to every step, 
absolute cleanliness, absolute hsemostasis, — these are 
the details which mark a new era in the development 
of the technique of gastroenterostomy. 

" It is coming to be recognized . . . that the nearer 
to the origin of the jejunum the anastomosis with the 
stomach is made, the more satisfactory is the convales- 
cence and subsequent course of any individual case 
[Fig. 2]. 

"The technique of posterior gastrojejunostomy as I 
am doing it to-day, without a loop, is as follows : an 
ample incision is made through the middle of the belly 
of the right rectus abdominis muscle. . . . Upon opening 
the abdomen the duodenum and the whole of the stomach 
should be examined carefully in order to detect possible 
lesions. . . . 

" The great omentum and transverse colon are lifted 
completely out of the wound at the upper angle of the 
wound, and placed upon a sterile towel covering the sterile 

1 C. L. Scudder, A nnals of Surgery, September, 1904. 



172 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

abdominal skin, thus exposing the under surface of the 
transverse mesocolon. While the left hand grasps the 
transverse colon and omentum, the fingers of the left 
hand push the posterior wall of the stomach in its pyloric 




Fig. 2. — To show the relation of the beginning of the jejunum to the posterior 
wall of the stomach under normal conditions. 

Note the tortuous course of the duodenum. Note that the natural place for 
the anastomosis between stomach and jejunum is where the jejunum rests 
against the posterior gastric wall. 

(After Scudder, in Annals of Surgery.) 



portion [italics ours] firmly against the meso-colon 
[Fig. 3]. The right hand incises with a knife (or tears) 
the transverse mesocolon, thus exposing the posterior 
wall of the stomach. 

« This incision is so placed that large vessels are 




Fig. 3. — To show the beginning of the jejunum and the peritoneal fold above 
the superior mesenteric vessel. To show the method of grasping with the left 
hand the transverse colon and the pushing the posterior stomach wall through 
the small rent made in the transverse mesocolon. The colic vessels supplying the 
colon are shown, as well as the vessels of the greater curvature of the stomach. 

The omentum is purposely omitted from the drawing. 

A line connecting the two points x and y indicates the best angle at which to 
apply the clamp to the stomach. 

(After Scudder, Annals of Surgery.) 

173 



174 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

avoided. Its direction is at right angles to the trans- 
verse colon's long axis. . . . The opening in the meso- 
colon should be four or five inches long. . . . The large 
colic vessel which nourishes the transverse mesocolon 
should of course be carefully avoided. 

" The posterior wall of the stomach is picked up by 
two pairs of dissecting toothed forceps, thus freeing it 
from the anterior wall of the stomach which is being 
pressed against it, and the stomach clamp ... is ap- 
plied. The clamp should be placed so as to avoid in- 
cluding, as far as possible, many large vessels. It must 
be remembered, however, that the large vessels mark 
the lowest border of the greater curvature of the stom- 
ach. . . . The clamp is placed a little obliquely upon 
the stomach in the line joining X and Y [Fig. 3]. 

"This oblique position is advantageous, according to 
Moynihan, for upon replacing the stomach and jejunum 
in the abdominal cavity after the anastomosis is com- 
pleted, the incision in the stomach lies most naturally 
against the jejunal incision without undue traction. 
The beginning of the jejunum is next sought a little to 
the left of the spinal column and at the attachment of 
the transverse mesocolon. The jejunum is picked up 
by two pairs of toothed forceps, placed opposite the 
mesenteric attachment, at that distance from the peri- 
toneal fold, marking the beginning of the jejunum, 
which is suitable to the case in hand. The nearer to 
the beginning of the jejunum the anastomosis can be 
made, the more satisfactory will be the result. The 
clamp is placed longitudinally upon the jejunum oppo- 
site to the mesenteric border. The anastomosis is made 
so that the peristaltic movement of the jejunum occurs 



OPERATIVE TREATMENT 



175 



in the same direction as the peristaltic movement of 
the stomach. The clamps upon the stomach and upon 
the jejunum are placed alongside of each other, thus 
bringing the parts of the stomach and jejunum to be 
anastomosed into close apposition, entirely outside the 
abdominal cavity. 




Fit;. 4. — To show the clamps applied to the stomach above and to the jejunum 
below. Note the angle at which clamps are applied. Note the strip of gauze 
between clamps posteriorly. Note the first half of the peritoneal suture being 
taken. Note that the suture is not drawn as tightly as usual in order that it 
may be seen in the drawing. 

(After Scndder, Annals of Surgery.) 



"The omentum and transverse colon are now, if 
possible, replaced within the abdomen. 

"The first, or peritoneal, suture is now taken with 
curved needle and No. 3 Pagenstecher linen thread. The 
suture is started at a point farthest from the surgeon 
and is made toward the surgeon. The sutures include 



176 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

peritoneum and muscular coats. The Gushing suture is 
used. The initial end of the suture is left long. The 
curved needle is of such a size that it may with ease be 




Scudder. 



Fig. 5. — To show the removal hy scissors of the prolapsed mucous membrane 
of the stomach, after the incisions into the stomach and intestine. Note that the 
mucous membrane from the jejunal opening has been already removed. Note 
that enough is removed to make the peritoneum and mucous membrane level. 
The first half of the peritoneal suture is shown completed. The gut is seen 
grasped by the clamps at the mid-portions of the blades of the clamps to secure 
evenness of pressure. 

(After Scudder, Annals of Surgery.) 

used without a needle-holder. . . . Having completed 
the first half of the peritoneal suture, the thread is left 
long [Fig. 4]. . . . 

"The stomach and jejunum are next opened by a 



OPERATIVE TREATMENT 



177 



knife incision parallel with the line of suture just com- 
pleted. The incision in the jejunum is therefore a 
longitudinal one. (The transverse incision of Mikulicz 
and Kocher limits the size of the opening.) The 
incisions are placed about one-half inch from the 
line of peritoneal suture. . . . The size of the open 




Fig. 6. — To show the taking of the first half of the through-and-through or 
haemostatic suture. 

Note at the beginning that a seroserous suture is taken and tied, that then the 
needle passes into the gut and then through and through all layers of both intes- 
tine and stomach walls. It is an over-and-over, through-and-through continuous 
suture. 

(After Scudder, Annals of Surgery.) 

ing made will depend upon the physical conditions 
present. An opening of from two and one-half to 
three inches is ordinarily needed. Intestinal contents 
and stomach contents are carefully removed by tiny 
gauze sponges at hand for this purpose. . . . The 
prolapsed mucous membrane of both the stomach 
and the jejunum is excised ... by means of scissors 



178 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

so that the mucous membrane is level with the perito- 
neum [Fig. 5]. . . . 

" The first half of the second suture is now taken 
with a straight No. 6 milliner's needle and No. 3 Pagen- 
stecher thread. . . . This suture is begun by taking a 
peritoneal and muscular stitch through both stomach and 




Fig. 7. — To show the second half of the second or through-and-through suture. 

The needle passes always from mucous memhrane to peritoneum on one side 
to peritoneum and mucous memhrane upon the other side, and then the peritoneal 
surfaces are always brought into apposition. Note the needle is beginning the 
return suture. 

(After Scudder, Annals of Surgery.) 



intestine [Fig. 6]. The needle is then carried into the 
lumen of the bowel and through and through all coats 
of both jejunum and stomach in an over-and-over con- 
tinuous suture ; . . . upon reaching the end of this suture 
the needle is carried out from the lumen of the bowel 
through the peritoneum and tied to the initial peritoneal 



OPERATIVE TREATMENT 



179 



stitch. Thus peritoneal surfaces are brought into close 
contact throughout this whole suture. . . . 

" Both clamps are now loosened. One of the clamps 
is removed. The other is left in place but open, as sug- 




Seudder. 



Fig. 8. — To show the completion of the second half of the through-and-through 
suture. Note how the opening has been gradually closing. Note the needle 
finishing the stitch. Note that, to finish suture ideally, the needle passes through 
peritoneum last, and is then tied to the first peritoneal suture used at the starting 
place. See figure. Thus peritoneal surfaces are brought into contact. 

(After Scudder, Annals of Surgery.) 

gested by Munro, that it may serve as a shelf upon 
which the bowel and stomach may rest and not slump 
into the abdominal cavity. . . . The lumen of the gut 



180 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

and stomach are now closed [Figs. 1 and 8], and all pos- 
sibility of soiling the peritoneal surfaces being elimi- 
nated, the whole region should be wiped with sponges 
wet with hot salt solution. , . . 




Fig. 9. — To show the second or through-and-through suture completed. To 
show the second half of the first or peritoneal Cushing suture. Note that the 
clamp upon the jejunum has been removed. Note that the clamp upon the stom- 
ach has been loosened, but that one blade has been retained to serve as a shelf to 
hold the part well without the abdomen, and thus to prevent slumping of the part 
until the suture is completed and the parts are cleansed finally. 

(After Scudder, Annals of Surgery.) 



" The second part of the peritoneal stitch is now com- 
plete [Fig. 9]. The whole field of operation being abso- 
lutely clean, the edges of the opening in the mesocolon 
are sutured to the posterior wall of the stomach in two 
or three places. . . . This prevents contraction of the 
opening and consequent subsequent constriction of the 
gut. This suture also prevents a hernia of the small 



OPERATIVE TREATMENT 181 

intestine into the lesser cavity of the omentum. . . . 
The distal portion of the jejunum is now replaced in its 
natural position, whatever this may be in the individual 
instance ; usually it is to the right of the spine. The 
omentum is replaced, covering all. The abdominal 
wound is closed." 

We have described this operation in Scudder's words, 
because he has covered the minutiae of the technique 
more faithfully than other writers, and because much of 
what he says applies equally to other operations at 
which we must glance. 

To the foregoing operation is applied the much-talked- 
of principle of the " short loop " ; more properly there 
is no loop [Fig. 10]. 

The operation with the " short loop " has now been 
used by a number of surgeons in a large number of 
cases. Physiologically it appears to approximate the 
normal conditions. The anastomosis is made opposite 
the second lumbar vertebra close (two to six inches) 
to the beginning of the jejunum, where it curls forward 
in normal approximation to the stomach, and that low 
portion of the stomach, near the pyloric area. So long 
ago as 1903 Trendel ! reported a very satisfactory series 
of cases from the clinics of Czerny, Steinthal, Bruns, 
and himself, operated upon by the short loop method. 

Trendel's series includes a large number of cancer 
cases, but even so the deaths in the total of two hun- 
dred and sixty-nine cases were only forty-nine, or 18.3 
per cent. The interesting and significant fact about 
the series, however, is that in not a single case was 
there established a true vicious circle. 

1 Belt. Klin. Chir., 1903. 







Fig. 10. — To show diagramrnatically the location of the opening secured by 
this operation between the stomach above and anteriorly and the jejunum below 
and posteriorly. S indicates the stomach cavity. / indicates the intestinal 
lumen. 

(After Scudder, Annals of Surgery.) 

182 



OPERATIVE TREATMENT 



183 



The number of operators who use the short loop 
method, both in Europe and America, is increasing, and 
their results are steadily satisfactory. As we have said, 
it is one of our two operations of choice when gastro- 
enterostomy must be done. 

Another operation, known as the operation of Chaput 
(Fig. 11), is posterior gastroenterostomy with the long 




Fig. 11. — Operation of Chaput. 

loop (fourteen to sixteen inches) plus entero-anastomosis, 
with section of the afferent loop between the anastomoses. 
Some surgeons take an even longer loop, — up to eigh- 
teen inches. The preliminary steps are similar to those 
already quoted. The loop in this case should be long 
enough to prevent any kiuking at the ligament of Treit, 



184 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

and to prevent spur formation at the anastomosis. We 
advocate an entero-enterostomy in these long loop cases, 
and unless there be some contra-indication, an occlusion 
of the afferent loop between the entero-anastomosis and 
the gastro-anastomosis. The resulting anatomical con- 
dition is, essentially, that produced by the so-called 
Roux operation, but the entero-enterostomy is a side-to- 
side instead of an end-to-side anastomosis. 

The occlusion may be secured either by infolding the 
bowel longitudinally without opening it, " emplication," 
or by actually resecting the gut. We prefer the 
resection. 

II. There is an extension of this operation of Chaput, 
— an extension which we regard as useful ; we refer 
to closure of the pylorus by section. The resulting 
anatomical arrangement of the parts is so near to the 
normal that ultimate impairment of function seems 
impossible. The steps of the operation are (1) posterior 
gastrojejunostomy with the long loop ; (2) entero- 
enterostomy (and for this the button is safe and 
speedy) ; (3) section of the afferent loop between the 
two anastomoses ; (4) section of the pylorus (Fig. 12). 

There result from this a stomach with one drainage 
canal, that canal straight and uncomplicated ; a duo- 
denum opening into the drainage canal four to six 
inches below the stomach, and that duodenum now 
converted into a mere continuation of the common bile- 
duct. 

This operation, in uncomplicated cases, is easy and 
rapid ; subsequent stomach drainage is simple and 
direct ; the new opening cannot close ; vicious circle 
is impossible ; and the resulting anatomical conditions 



OPERATIVE TREATMENT 



185 



approach more nearly to the normal than is seen after 
any other form of gastroenterostomy, hence any 



1 ^fe'-v 


m» : x v 






% ^ — ~~~~ \ 

Hi*' 


i 






! 



Fig. 12. — Operation of Chaput, plus section of the pylorus. 

additional risk incurred by the two resections appears 
to be justified. 1 

1 It goes without saying that this somewhat elaborate procedure 
should not be pushed to a conclusion in the presence of a failing pulse or 
threatening collapse of the patient. 



186 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

The operation of anterior gastroenterostomy, though 
in disfavor with many operators, is still practised by 
competent men. Bevan informs us that he habitually 
employs it, and has seen no reason to change his good 
opinion of it. It is performed, of course, as the name 
implies, by drawing the jejunum up over the omentum 
and attaching it to the lowest point available of the 
greater curvature of the stomach, — commonly in or 
near the pyloric region. Entero-enterostomy should 
always form an integral part of this operation. 

The writers have had little experience with the 
anterior operation, for their knowledge of the experi- 
ence of others turned them early to the posterior 
method. They feel strongly that either the first or 
third of the two posterior procedures already described 
is admirable. 

III. Another operation for stomach drainage, and 
the third of those we advocate especially, is that known 
by Finney's name. Having seen it in Finney's hands, 
and had some little experience with it ourselves, we 
have come to feel that it is a method of the greatest 
value. It is physiologically correct, for the stomach 
is left with its one natural drainage outlet. There is 
no possibility of vicious circle or jejunal ulcer. It was 
said at first by Finney that the operation is applicable 
only when non-malignant stenosis without active ulcer 
is present. That assumption has been proved untrue 
by the author of the operation, though doubtless it is 
a fact that in the face of some of the complicated pro- 
cesses associated with ulcer, — adhesions, distortions, 
etc., — the mechanical difficulties of a " Finney " may be 
insurmountable. 



OPERATIVE TREATMENT 187 

In a word, Finney's method consists in the substitut- 
ing of a large pjdorus for a small one. It combines 
the advantages of Jaboulay's or Kocher's gastro-duo- 
denostomy with the Heinecke-Mikulicz pyloroplasty. 
Properly, says Finney, the operation should be called 
" gastro-pyloro-duodenostomy." " Finney's pyloro- 
plasty " is sufficiently accurate and descriptive. We 
give his own words : — 

" Divide the adhesions binding the pylorus to the 
neighboring structures, also free as thoroughly as pos- 
sible the pyloric end of the stomach and first portion 
of the duodenum. Upon the thoroughness with which 
the pylorus, lower end of the stomach, and upper end 
of the duodenum are freed, depends, in a large measure, 
the success of the operation, and the ease and rapidity 
of its performance. I wish to emphasize this as one 
of the most important points in the operation. Fre- 
quently, at first sight, the pylorus may seem hopelessly 
bound down, when after a little patient toil and judi- 
cious use of the scalpel and blunt dissector, it is found 
that it can be freed with comparative ease. A suture, 
to be used as a retractor, is taken in the upper wall 
of the pylorus, which is then retracted upward. A 
second suture is then inserted into the anterior wall of 
the stomach, and a third into the anterior wall of the 
duodenum, at equidistant points, say about twelve 
centimetres, from the suture jnst described in the 
pylorus. These second sutures mark the lower ends of 
the gastric and duodenal incisions, respectively. They 
should be placed as low T as possible in order that the 
new pylorus may be amply large. Traction is then 
made upward on the pyloric suture, and downward 



188 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 



in the same plane, on the gastric and duodenal sutures. 
This keeps the stomach and duodenal walls taut, and 




Fig. 13. 
(After Finney.) 



allows the placing of the sutures with greater facility 
than if the walls remained lax. [See Fig. 13.1 The 




Fig. 14. 
(After Finney.) 



OPERATIVE TREATMENT 



189 



peritoneal surfaces of the duodenum and stomach, 
along its greater curvature, are then sutured together, 
as far posteriorly as possible. [See Fig. 14.] For 
this row I would recommend the use of the continu- 
ous suture, as it is more easily and quickly applied, 
and it can be reenforced after the stomach and duo- 
denum have been incised. After the posterior line of 
sutures has been placed, an anterior row of mattress 




Fig. 15. 
(After Finney.) 

sutures is taken, which are not tied but left long in 
the manner indicated in Fig. 15. These sutures, after 
they have been placed, are retracted vertically in either 
direction, from the middle of the portion included in the 
row of sutures. [See Fig. 16.] Then, after all the 
stitches have been placed and retracted, the incision is 
made in the shape of a horseshoe. The sutures should 
be placed far enough apart to give ample room for the 
incision. The gastric arm of the incision is made 



190 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

through the stomach wall just inside the lowest point 
of the line of sutures, and is carried up to and through 
the pylorus and around into the duodenum, down to 
the corresponding point on the duodenal side. Hem- 
orrhage is then stopped. It is well to excise as much 
as possible of the scar tissue upon either side of the 
incision in order to limit, as far as possible, the sub- 
sequent contraction of the cicatrix. This procedure I 




Fig. 16. 

(After Finney.) 

carried out in two of my cases with great satisfaction, 
and I should strongly recommend it in all cases where 
the walls of the pylorus are much thickened and there 
is much scar tissue present. It is well, too, to trim oft 
with scissors redundant edges of mucous membrane, ana 
prevent the reunion of the divided intestinal walls, 
The anterior sutures are then straightened out and tied 
[Fig. 171, and the operation is complete, unless one 
wishes to reenforce the mattress sutures with a few 



OPERATIVE TREATMENT 



191 



Lembert stitches. [See Fig. 18.] This procedure, as 
is readily seen, gives the minimum of exposure of in- 




Fig. 17. 

(After Finney.) 



fected surface. All the stitches are placed and the 
posterior row tied before the bowel is opened, and it 




Fig. 18. 
(After Finney.) 



192 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

remains open just long enough to control the hemor- 
rhage. The size of the newly formed pyloric opening 
is limited in this operation only by the mobility of the 
stomach and duodenum, and the judgment of the 
operator. In all of my cases the incision has been 
about twelve centimetres in length, and could have 
been made longer, had I chosen to make it so. Un- 
less the stomach is very much dilated or has descended 
to an unusual extent, the lower limit of the new outlet 
is at or near the level of its most dependent portion. 

" When the stomach is much dilated, there is no con- 
tra-indication in this operation to the performance, at 
the same time, of gastropexy or gastroplication, if one 
considers them indicated." 

The old Heinecke-Mikulicz pyloroplasty has fallen 
into disfavor and is now rarely employed. It was well 
enough so far as it went, — that is, it restored the 
pylorus to a normal caliber ; but it afforded inadequate 
drainage for a dilated or dislocated stomach. More- 
over, many cases of recontraction have been reported. 
Finney's operation overcomes these difficulties. The 
opening may be carried far down in a dilated stomach 
and the great opening secured cannot conceivably close 
unless it be again extensively involved in disease. The 
opening supplies admirable drainage and from the 
pyloric region too. One objection to it is involved in 
the question of partial gastrectomy as practised by 
Rodman. Rodman's theorem is founded on the multi- 
plicity of ulcer and its probable change to cancer. 
Now ulcer and cancer are found mostly in the pyloric 
portion and in the duodenum. Therefore Rodman 
proposes to combine drainage operations with excision 



OPERATIVE TREATMENT 193 

of the cancer-bearing pyloric region. This is one of the 
questions of gastric surgery which is being debated. It 
is not improbable that we shall come to adopt in part 
Rodman's apparently radical views. 

That form of gastroenterostomy which has come to 
be known as the operation of Roux, though essentially 
the same at that of Wolfler, is interesting and impor- 
tant. The method of this well-known procedure is to 
cut in two the jejunum about sixteen inches from its 
beginning, and implant the distal or efferent end into 
the stomach. The proximal end (duodenal portion) is 
then implanted into the distal end about eight inches 
from the new stomach opening. The resulting forma- 
tion has appropriately been called " en Y." 

The various modifications of gastroenterostomy have 
been devised to minimize the chances of vicious circle, 
one of the most serious complications that may follow 
gastroenterostomy. 

Now vicious circle 1 is a much abused and misunder- 
stood term. For the establishment of a vicious circle 
a patent pylorus is essential ; and by the term " vicious 
circle " we mean to indicate the current set up by the 
passage of stomach contents by the way of the pylorus 
into the duodenum, and then through the anastomosis 
back into the stomach. So the orbit of the vicious 
circle is always confined to the afferent loop and the 
stomach. "Reflux vomiting" is said to be due to the 
flow of bile and pancreatic secretion into the stomach. 
Whether such back flow does or does not cause vomiting, 
it would appear that true reflux vomiting has sometimes 

1 See important article on " Gastro-enterostomy " by Cannon and Blake, 
in Annals of Surgery for May, 1905. 
o 



194 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

occurred from retro-peristalsis of the jejunum, causing 
return of chyle to the stomach. Various reasons for the 
vicious circle have been advanced. They all come down 
to the question of some sort of mechanical obstruction 
to the easy on-flow of intestinal contents, or to an intes- 
tinal paralysis. If there are adhesions about the efferent 
loop, stomach contents more easily gravitate to the affer- 
ent loop. If there are obstructing spurs or kinks, a simi- 
lar catastrophe results. In the same way, with an open 
pylorus, and a very long afferent loop crippled by adhe- 
sions, it is probable that food and secretions may accu- 
mulate in the duodenum and be returned to the stomach. 

Even with the Wolfler-Roux technique, reflux vomit- 
ing may occur. Fowler has introduced the manoeuvre 
of occluding the afferent loop by an encircling silver 
wire between an entero-anastomosis and the gastro- 
anastomosis. This is essentially the operation w r e have 
already described, — the operation of Chaput, which 
cuts off the bow T el, while Fowder occludes simply. 

This is no place for an extended discussion of tech- 
nique. To one important conclusion we have come, 
however. No one method is applicable to all cases. 
The surgeon must be guided by his findings. 

We wish also to point out this fact : when the short 
loop of Czerny, von Mikulicz, Moynihan, has been used, 
vicious circle vomiting has not occurred, so far as 
reports tell. Reflux vomiting from adhesions is pos- 
sible with the short loop, but it must be very rare. 1 

Another matter of technique which has much agi- 

1 For a valuable discussion of the subject of vicious circle and various 
methods, we refer the reader to G. R. Fowler's important article, Annals 
of Surgery, Vol. XXXVI, p. 695, 1902. 



OPERATIVE TREATMENT 195 

tated the surgical world is the question of mechanical 
devices for anastomosis. Such devices have been nu- 
merous, but to-day we see two which are popular, — 
the Murphy button and the McGraw ligature. Har- 
rington's segmented ring is also gaining favor. Many 
surgeons, and we are among the number, prefer to use 
no mechanical device, whenever possible. It is fair to 
assert, we believe, that, on the whole, stitching the 
viscera to each other is the safest procedure, for then 
the dangers of breaking down, leakage, narrowing, and 
retention of a foreign body are reduced to a minimum. 
On the other hand, when speed is a desideratum, the 
button has its advantages ; while for the same reason 
the McGraw ligature has become popular with some 
operators. We must in fairness recognize the advan- 
tages of such appliances, though we cannot sympathize 
with the enthusiasm of those who always use them. 

The reader will observe that we have described these 
operations for drainage as the essential operations for 
non-malignant stomach disease. This rule of drainage 
applies to bleeding ulcer as well as to other pathological 
conditions. Sometimes the surgeon may be tempted to 
explore the stomach and deal directly with a supposed 
bleeding vessel ; but in the great majority of cases this 
is needless and increases the danger. Drainage alone 
suffices. 

In the case of suspicious tumors or thickening of the 
gastric wall, however, exploration is advisable often. 
It not infrequently happens that even an exploration 
fails to distinguish malignant disease from an ulcer 
with a greatly thickened base. In such case, if in 
doubt as to the diagnosis, gastrectomy is our operation 



196 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

of choice. We shall describe gastrectomy in the next 
chapter. 

The complications to be dreaded and the causes of 
death after drainage operations are exhaustion, persist- 
ent vomiting, pneumonia, and a break-down of the 
anastomosis with peritonitis. The methods of meeting 
these complications rest on general surgical principles. 
A proper selection and a careful preliminary prepara- 
tion of the patient are extremely important. Post- 
operative stimulation, nutrient enemata, early feeding, 
elevation of the shoulders, plenty of water by the 
mouth, rectum, or under the skin, will suggest them- 
selves to the reader. 

Persistent vomiting probably means the vicious circle, 
which may develop early or after weeks, in which latter 
case it is doubtless due to cicatrices or the partial clos- 
ing of the anastomosis. In such cases an exploration is 
imperative, when one may find that the breaking up of 
adhesions, an entero-enterostomy, a pylorectomy, or even 
a secondary gastroenterostomy are demanded to correct 
the condition. 

Why the development of pneumonia follows gastro- 
enterostomy is not always apparent, but- experience 
shows that that is a complication to be dreaded. 

Finally, that desperate calamity, a break-down of 
the anastomosis, demands the most active interven- 
tion if the patient is to be saved. With increasing 
experience and improved technique this catastrophe is 
infrequently seen. 

Peptic ulcer of the jejunum, at the seat of the anas- 
tomosis, is another possible danger, but so remote that 
it is not seriously to be dreaded. In proportion to the 



OPERATIVE TREATMENT 197 

total number of operations reported this accident is 
very rare. 

Such, in brief outline, are the striking conditions of 
non-malignant stomach surgery as we see them to-day. 

These diseases are frequently and properly subject to 
operative treatment. The universally applicable opera- 
tion is some form of stomach drainage. 

Experience leads us to believe that posterior gastro- 
enterostomy with (1) the short loop, (2) the long loop 
with entero-enterostomy and occlusion of the afferent 
limb plus obliteration of the pylorus, and (3) the method 
of Finney, are the three operations of choice. 



CHAPTER VII 
CANCER OF THE STOMACH 

It is a simple solution of the difficulty to say that 
operation for cancer of the stomach is never justifiable. 

Even four years ago many of us were ready to agree 
with Fitz that " Exploratory laparotomies, whether by 
advice of the physician, desire of the surgeon, or urgency 
of the patient, are only too frequent." Bevan, publish- 
ing in 1903, said, " The mortality [in gastric cancer] is 
still large, and the final results in gastro-enterostomy 
and pylorectomy and partial and complete gastrectomy 
are such as almost to warrant the statement that all 
operations for malignant disease of the stomach are 
but palliative and not curative in character." So, too, 
Moynihan, in 1903, in a long and critical review of the 
subject, quoting liberally from the figures of Kronlein 
and von Mikulicz, was forced to the conclusion that, at 
the best, operation offers but a sad alternative to a 
natural death, and that so radical a procedure as total 
gastrectomy is but rarely permissible ; x while J. B. 
Murphy, in the same year, though arguing earnestly for 
early diagnosis by exploration, showed by a great array 
of figures that up to that time the operative record was 
pitiable. 2 

Are we, then, to conclude that the question of the 
treatment of stomach cancer must be one largely of the 

1 British Medical Journal, Dec. 5, 1903. 

2 Annals of Surgery, December, 1903. 

198 



CANCER OF THE STOMACH 199 

individual temperament of the patient ? Statistics are 
interesting, but in the last analysis, is not the victim 
asked in effect whether he will make the journey to 
Tyburn by the way of Maiden Lane or Piccadilly ? It 
is true that some few patients have been cured by gas- 
trectomy, but the number is discouragingly small. For 
the vast majority the question is whether to die in the 
normal way or to submit to the wretchedness of an 
abdominal section with a fair chance of living a few 
months longer than nature intended. I who write this 
was for several years a practitioner of general medicine. 
I saw many cases of gastric cancer from the beginning 
of their symptoms. Some were operated upon, some 
were not. I am forced to admit that in those days 
and in the long run the patients fared best who were 
left to die. More than almost any other class these 
cases should be approached from the humanitarian 
standpoint. Some victims will take almost any risk 
for the sake of prolonging life ; others prefer to die 
rather than drag out a miserable existence. So let 
each man choose. 

It is not quite fair to compare, as has been done, this 
field of surgery with that existing a few years ago in 
the case of breast cancer. Disease of the breast may 
be recognized early ; it does not strike so deeply and 
immediately at an important vital centre ; in the minds 
of the laity, it is not associated with such horror ; as a 
rule it runs a far longer course, unaccompanied by such 
a variety of distressing symptoms ; cures by operation 
are far more frequent and attended with less immediate 
risk to life, even when the disease is advanced ; the 
management of the convalescence is less difficult, and in 



200 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

the case of recurrence, the lesion, being on the surface 
in most cases, lends itself more readily to palliative 
treatment. Argue as we may, we cannot get round the 
fact that surgery of malignant stomach disease is one of 
the most difficult in our art, — calling for the nicest 
judgment, rare skill, and great experience, not lightly 
to be entered upon by the average operator. Nor must 
we expect that with time and the perfecting of our 
technique the conditions will become simpler. Any 
man of fair training may amputate a breast, may dis- 
sect the axilla, or may remove a chronically diseased 
appendix ; but only those especially skilled will ever be 
able to open the abdomen and deal successfully with 
the complicated and dangerous conditions so fre- 
quently found associated with malignant disease of 
the stomach. 

This is no new field of labor. It is more than 
twenty-five years since Pean, in 1879, attempted a pylo- 
rectomy, — unsuccessfully, — to be followed by Rydygier 
in 1880. Billroth improved the operation and saved his 
first patient in 1881. His two methods are still taught 
in the schools. Scattering operators followed, with 
indifferent success. As early as 1883 Connor of Cincin- 
nati performed total gastrectomy, but his patient died. 
In 1897 Schlatter was successful with a total gastrec- 
tomy. 

In 1883 and in 1885 Courvoisier and then von Hacker 
devised posterior gastro-enterostomy, though as early as 
1881 Wolfler had made an anterior anastomosis ; while 
it was not until 1894 that Jaboulay first performed 
gastro-duodenostomy. 

So experience accumulated and technique improved 



CANCER OF THE STOMACH 201 

until to-day, when the list of surgeons includes Kocher, 
Roux, Maydl, Czerny, von Mikulicz, Kronlein, Wolfler, 
von Eiselsberg, Robson, Moynihan, the Mayos, Senn, 
Deaver, Murphy, Richardson, Bevan, Finney, and Wyllys 
Andrews as the most conspicuous modern exponents of 
this field of surgery. 

Cancer of the stomach is a subject properly treated 
in this book. Gastric cancer is a digestive disorder. It 
is frequent ; associated with certain prodromata it is 
common ; it gives rise to marked symptoms ; it is 
chronic in a sense ; it is insidious ; it is fatal. Accord- 
ing to von Mikulicz and W. J. Mayo, one-third of all 
cancers are found in the stomach, and 2 per cent of all 
deaths are due to cancer of the stomach. We have been 
taught that it is a disease of sudden onset, coming on in 
persons of previously good health and strong digestion. 
Robson and Moynihan repeat the assertion. On the 
other hand, American operators have come to believe 
that cancer often develops at the end of a long dyspeptic 
career, and this is our own conviction, as we have already 
asserted. Von Mikulicz says 7 per cent follow old ulcer, 
while W. J. Mayo states that " A very large proportion 
of the cases which we have had gave an early history of 
ulcer of the stomach." Geography may have something 
to do with these divergent opinions, but we feel we can 
assert positively and on strong grounds that in America 
ulcer and other inflammatory processes are common 
forerunners of, if not actual etiological factors in, the 
production of gastric cancer. 

We have made a personal study of some fifty cases of 
cancer of the stomach at the Massachusetts General 
Hospital ? and in forty-one of the cases there was a 



202 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

histor}' either of ulcer or of long-continued digestive 
disturbance, of which the exact nature could not be 
ascertained. Since these facts have been borne in upon 
us we have questioned closely all persons in whom a 
diagnosis of gastric cancer could be made, and rarely 
have we failed to elicit a history of digestive derange- 
ments extending over several years. 

Carcinoma of the stomach is primary in the great 
majority of cases, while of those gastric cancers which 
are secondary, most are merely extensions from a 
primary focus in the oesophagus. Having regard, then, 
only for those originating in the stomach, how are we 
to make the diagnosis ? 

In the first place, there is that factor of long-standing 
stomach disorder in persons over forty years of age. 
Von Mikulicz finds that men and women are about 
equally affected, and we know, of course, that cancer of 
the stomach occurs occasionally in young subjects. But 
take the patient over forty years of age with a history 
of stomach trouble, — heartburn, a sense of oppression, 
distress after food, increasing anorexia (especially dis- 
taste for meat), occasional nausea, perhaps vomiting, 
— all that should arouse our suspicion. Von Mikulicz 
believes that gastric cancer, like cancer elsewhere, may 
remain latent for a long time, though the average dura- 
tion of life is but twelve months. 

Such symptoms as we have given are suggestive 
merely ; they do not admit of a positive diagnosis. Of 
course pain, vomiting, hemorrhage, tumor, are late and 
characteristic evidence. 1 

Will an analysis of the stomach contents help us in 
1 See Appendix. 



CANCER OF THE STOMACH 203 

the early stages ? Unfortunately it will not, usually. Gas- 
tric motility may be diminished or it may be increased ; 
hydrochloric acid may be absent, but more often it is 
present; the Oppler-Boas bacillus — a long non-motile 
organism, of the shape of a baseball bat — is present 
first or last probably in a majority of these cancer cases, 
but it is likely to be a late manifestation. The presence 
of lactic acid is evidence of some value, but its absence 
is of no significance. Traces of blood, discovered by the 
guaiac test properly performed, are extremely significant, 
however. 

Can we then recognize or treat these early cases, in 
which we have such good reason to believe that a trans- 
formation from a benign to a malignant condition is in 
progress? Murphy, in a suggestive paper, in a vein of 
cautious optimism, has answered this question in the 
affirmative. 1 To the questions : " Do we recognize the 
transition ? " he replies, " No " ; " Can we ? " he answers, 
" Yes." He asks : " How soon after the penetration of 
the basement membrane by these erratic epithelial cells 
are symptoms manifest, and what are the symptoms ? 
Second, how soon after the penetration of the base- 
ment membrane by these erratic epithelial cells are the 
cells transmitted (a) through the lymph spaces to ad- 
jacent areas in stomach walls, (J) through lymphatic 
drains to neighboring lymph nodes, (c) through the 
lymphatics to the first filter gland, (d) from the pri- 
mary filter gland to second and subsequent filter 
glands, (V) from the last filter gland to the chyle 
duct ? How do they pass through the pulmonary capil- 
laries ? Where and how do they produce elective metas- 
i Annals of Surgery, Vol. XXXVIII, p. 791, 1903. 



204 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

tases ? " These are searching questions, and the answei 
is not yet. 

Another reason, if reason be needed, for believing 
that cancer develops on the site of benign precancerous 
lesions is that the location of the two is very similar, as 
shown by the following table, taken from Robson and 
Moynihan : — 



Location 


Ulcxb 


Cancer 


Pylorus and lesser curvature 

Posterior surface 

Cardia 

Greater curvature 

Anterior surface 

Fundus 


51.6% 
25 

7.9 

4.14 

8 

3.3 


70 
4 
9 
4 
3 

10 



The only marked divergence in the two rows of 
figures appears to be in lesions of the posterior surface. 
Ulcer of the posterior surface is common, while cancer 
is rare on that site. The great majority both of 
cancers and ulcers, however, are found near the pylorus, 
in what we have come to recognize as the ulcer-bearing 
area. 

The purpose of our argument is, through an examina- 
tion of conditions, to ascertain, if possible, whether the 
pathological situation is hopeless or capable of ameliora- 
tion, and to point out in what fashion, through surgery, 
that amelioration shall be sought. In the present state 
of our knowledge, with the exact nature of cancer in 
dispute, we can look for no cure through the measures 
of the internist. 

From these and similar statistics we may conclude 
that cancer of the stomach is a primary disease of in- 



CANCER OF THE STOMACH 205 

sidious onset ; 1 that it is usually located in the lower 
or pyloric region, and so is accessible to operative treat- 
ment, if taken early. Let us now consider briefly the 
probability of its spreading ; especially let us consider 
the routes through which metastasis is most likely to 
occur. 

Be it stated at the outset that in from 4 to 10 per cent 
of the cases no metastasis has been found, the enlarged 
glands present being shown to be merely hyperplastic. 
Therefore we may fairly say that in about one of twenty 
cases the chance of recurrence after gastrectomy is by 
so much decreased. Such glandular hyperplasia exists 
often in the case of ulcer also, and in the course of 
operation the glands should be sought and followed up, 
for thus we may light upon the site of the ulcer, as 
Lund has stated. 

Cuneo and Most have demonstrated the lymphatic 
connections of the stomach. These connections may be 
divided into three distinct fields, which should be kept 
clearly in mind : — 

1. The field of the fundus. 

2. The superior gastric field. 

3. The anterior gastric field. 

Note at once this important fact : that the fundus is 
rarely the seat of carcinoma, and that its lymphatic 
glands are seldom involved. W. J. Mayo describes this 
condition as " the lymphatic isolation of the dome of 
the stomach." Owing to this local immunity, the 
fundus usually may be preserved in resections of the 

1 To quote W. J. Mayo, Annals of Surgery, March, 1904 : — 

" Graham, in one hundred and forty-five cases of cancer of the 

stomach, which came to operation at oar hands, found a previous history 

of ulcer of the stomach in 60 per cent of the cases." 



206 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

organ. Such few lymph channels as there are in this 
upper left-hand portion of the stomach drain toward 
the spleen. 

The superior gastric field is the greater portion of the 
anterior and posterior walls of the stomach, including 
the pyloric region. Drainage here is toward the lesser 
curvature and the cardia as far upward and to the left 
as the gastric artery. In extirpation of most gastric 
cancers this is the important field for removal. 

The anterior gastric field comprises the right half 
of the greater curvature and some small portion of 
the anterior and posterior walls. Thence the lymph 
stream is conducted into a few glands lying in the 
gastrocolic omentum and grouped mainly toward the 
pyloric end of the stomach. W. J. Mayo's cut (Fig. 19), 
adapted from Hartmann and Cuneo, illustrates admirably 
these arrangements. Note always the fact that most 
commonly the glands from cancer are found along the 
lesser curvature, those from ulcer along the greater 
curvature. 

Finally, and in addition to these three groups of 
glands, there are those lying between the stomach and 
pancreas and along the cceliac axis and splenic artery. 
If these are diseased, their removal is almost impossible. 
Hence, as von Mikulicz remarks, " If these glands are 
clearly involved, a radical operation in most cases had 
better not be attempted." 

The growths giving rise to malignant lymph nodes 
are roughly divided into cylindrical carcinomata and 
spheroidal carcinomata. The former include those vari- 
ously designated " adeno-carcinoma," and " cylinder- 
epithelioma," or " destructive adenoma." The terms 



CANCER OF THE STOMACH 201 

"scirrhus " and " medullary " are used merely to indicate 
an excessive or scanty amount of fibrous tissue stroma. 
In both varieties degenerative and ulcerative processes 
are common, but the former or cylindrical variety is the 
better suited to surgical treatment. 

Though cancer of the stomach is most common in 
the pyloric region, frequently obstructing or completely 
blocking that outlet, it rarely extends more than an 
inch into the duodenum, — a circumstance to be noted, 
— but it frequently involves other organs. That is a 
grave fact. Advanced gastric cancer is sure to spread 
by direct contact. The liver, the pancreas, gall-bladder, 
ducts, intestines, omentum, diaphragm, and even ab- 
dominal wall may be involved. There is no limit to 
the possibilities. Such extension and involvement may 
of course put radical operations out of the question 
except in those rare cases in which, the colon alone 
being secondarily attacked, a resection of that viscus 
may be done at the same time that gastrectomy is 
performed. 

Such, in brief, being some of the conditions we have 
to face, let us now consider in more or less detail the 
technique of the two most important operations which 
concern us in this connection ; and afterward let us 
attempt to estimate in how far such operations may be 
justified. 

Gastro-enterostomy and pylorectomy, or gastrectomy, 
are the operations we must study. Of gastro-enteros- 
tomy, which is a palliative procedure consisting of 
making an anastomosis between greater curvature and 
jejunum, little need be said. Its purpose is merely to 
anticipate starvation due to an obstructed pylorus. It 



208 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

side-tracks cancer of the pylorus and does nothing else. 
It is never indicated except there be obstruction, — 
never in disease of the fundus or cardia. In passing, let 
us observe that in the case of threatening starvation 
from oesophageal obstruction or cancer of the fundus, 
some form of gastrostomy, — Witzel's or Kader's 
method if you choose, — or a jejunostomy, may be indi- 
cated, at the discretion of the surgeon. 

Sometimes one may do a posterior gastroenterostomy 
for pyloric obstruction, sometimes and more commonly, 
an anterior operation, owing to the presence of difficult 
complicating posterior adhesions. A favorite and satis- 
factory method is by the Murphy button, as speed is 
generally essential. The McGraw ligature is popular 
with many surgeons when operating under these condi- 
tions. 

Gastrectomy, however, is the operation which in- 
terests us especially, — partial gastrectom}' or some- 
times a mere pylorectomy ; and various methods of 
performing gastrectomy have been devised. Billroth's 
first method consisted of cutting out the pyloric tumor, 
leaving a narrow duodenal margin, but taking off a con- 
siderable portion of the stomach. The stomach wound 
was then closed except for a narrow opening at the 
lower portion, into which opening the cut end of the 
duodenum was inserted. Naturally there was a suture 
angle left where the two organs were united, and at 
this angle leakage sometimes occurred. They came to 
call this « the fatal suture angle." 

Billroth's second method consists in closing the cut 
ends of both stomach and duodenum and doing a 
gastrojejunostomy, — obviously a safer and better pro- 



CANCER OF THE STOMACH 



209 



cedure. Kocher makes an anastomosis between the 
posterior wall of the stomach and the duodenum, after 
closing his original stomach wound. Both of these 
operations are sound and valuable. With certain modi- 
fications employed by individual operators, they are 









■ 




Pneumogastric 
left 






s^m 




Ganglion 

Pneumogastric 
right 


- — 


\^K£^ 


*$L — ' 


1 


Coronary artery 
Coronary vein 






SgfcS^. mwtg 












Ganglion 1 
Hepatic artery 








Ww 


Gastroepiploic 

artery \ 




■ 


© 


m\ $ 


Ganglion 








H 


Gastroepiploic 
vein : 

i 


From Hdrt 1)1(1 111) and C\ -o . 
,), -v.l 







Fig. 19. — Showing anatomy of the stomach with especial reference to distri- 
bution of the lymphatics. 

(After W. J. Mayo, Annals of Surgery.) 

now in common use, — Billroth's second operation being 
perhaps the more popular, as the frequent immobility 
of the duodenum renders Kocher's gastro-duodenostomy 
sometimes difficult or impossible. 

In our opinion the gastrectomy described by W. J, 



210 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Mayo, and founded on Billroth's second method, is most 
satisfactory and always applicable when any gastrec- 
tomy is permissible. 

Somewhat paraphrased and abbreviated, his descrip- 
tion is as follows : 1 — 

In all cases the operation of gastrectomy may be out- 
lined for convenience in six paragraphs. This Mayo 
does thus : — 

A. Incision and exposure. 

B. Control of hemorrhage. 

G Excision of the stomach with tumor. 

D. Reestablishment of the gastro-intestinal canal. 

E. Avoidance of infection. 

F. Prevention of shock. 

A. In the first place, explore to see whether or not 
operation shall be done, and what operation. A short 
median incision about the middle of the epigastrium 
answers well. If necessary, it may later be extended 
in either direction. After exploring, if it seems best to 
abandon any further operation, sew up as quickly as 
possible and get the patient back to bed. In most of 
the cases the writers have been satisfied with the 
rapidly inserted, through-and-through silkworm-gut or 
wire sutures. They are removed in a week and, with 
the wound reenforced by straps, the patient is gotten 
out of bed. Mayo, with excellent reason, prefers to 
sew with buried wire or silk. Either method has 
seemed satisfactory to us, the principle being the same 
in both. 

If, now, we have decided to proceed with the operation, 
the incision is rapidly enlarged as much as seems best. 

1 Annals of Surgery, March, 1904. 



CANCER OF THE STOMACH 



211 



The writers prefer a long incision — ensiform to navel, if 
necessary — and have seen no hernia come from it. The 
next and immediate procedure is to tie off the gastro- 







| 




^^T^^^ 


Willi/vm J. jMno. 




Mk§|%-;- 




/ Jt 




»*- - \ 


'llm^tfflilS! 




I 




i^^B ^i'^'wi 


bsbpt^^ v \ ~N^^^A 


V ^^^1 


•a v£ ^ 


i ■ 




" » ' > y -TW V :• 


■^— -^ v ^~~ ss ^^\^■p|j 


1L/ 




f- 


^U| 


IPISi 


,'" 




ip ^ 


iip^p 


y 


■K^ _^-^ - 



Fig. 20. — Showing ligation of gastrohepatic omentum and superior vessels in 
such manner as to leave all the lymph nodes attached to the part of the stomach 
to be excised ; also lines of division of duodenum and stomach. 

(After W. J. Mayo, Annals of Surgery.) 



hepatic omentum close to the liver, thus opening widely 
the lesser cavity of the omentum and mobilizing the 
pyloric end of the stomach (Fig. 20) ; for be it remem- 
bered always that in this discussion we are considering 



212 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

cancer of the pyloric end. The entire area exposed is 
packed off with gauze. 

B. The control of hemorrhage in these extensive 
stomach operations is an extremely important matter; 
but as Mayo remarks, when the principle of ligaturing 
four important arteries is intelligently grasped, the 
procedure is no more difficult than is that of securing 
the vessels in an abdominal hysterectomy. There are 
two arteries to be tied above the stomach — the gastric 
and the superior pyloric ; and two arteries below — 
the right and left gastro-epiploics. The gastric artery 
is best secured at once by a double ligature, where it 
joins the lesser curvature, about an inch below the 
cardia. The superior pyloric, a branch of the hepatic, 
is easily found and tied just above the pylorus. Then 
to get at the two lower vessels a hand is passed into the 
lesser cavity behind the pylorus, the gastrocolic omen- 
tum is found and elevated from the transverse meso- 
colon, and the right gastro-epiploic artery is thus 
isolated and secured from the front. Then the left 
gastro-epiploic artery is tied at a suitable point and the 
intervening ' gastrocolic omentum is secured and cut 
away. Mayo points out that in performing these last 
manoeuvres great care should be used not to interfere 
with the middle colic artery which runs beneath in the 
transverse mesocolon and supplies the transverse colon. 

C. The removal of a portion of the stomach is now a 
comparatively simple matter (Fig. 21) : Double clamp 
the duodenum and divide it with the cautery between 
the clamps. The stump of the duodenum is left pro- 
truding about a quarter of an inch from the lower clamp 
and a continuous catgut stitch is run in, uniting through 



CANCER OF THE STOMACH 



213 



all layers the edges before the clamp is removed. Then 
the stump of the duodenum is turned in with a purse- 
string silk suture, and so left. The second portion of 



^T ^\^^ ,uJ.M, Y0 . 

9] mJSml ^'^L^^kV Writ 


wmmj&~+*c\Afzm 


%^JwlfiL\ i\ 





Fig. 21. — Showing methods of excision. Note that all the glands on tli^ 
greater curvature are removed in every case. 
(After W. J. Mayo, Annals of Surgery.) 



the excision through the body of the stomach itself is 
accomplished in much the same fashion, though on a 
larger scale. The viscus is first securely grasped by 
one of the rubber-guarded holding clamps, on which 



214 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Kocher lays such stress, while just below it, at an in- 
terval of half an inch, is placed from below upward a 
strong biting clamp to prevent leakage. These clamps, 
when in place, run from Mickulicz's point of election 




Fig. 22. — Showing closure of cut duodenal end by circular suture and first 
row of sutures being placed on the stomach side. 
(After W. J. Mayo, Annals of Surgery .) 

above — that is, from the severed gastric artery — to 
Hartmann's point of election below. Then cut off 
w T ith the cautery the stomach between the two clamps 
and so remove the tumor. The severed edges of the 
stomach stump are caught together with a catgut button- 



CANCER OF THE STOMACH 



215 



hole stitch and the line of suture is then turned in with 
Lembert stitches applied preferably on the right-angled 
plan recommended by Cushing (Fig. 22). Our admi- 
rable cuts borrowed from W. J. Mayo illustrate these 




Fig. 23. — Showing completed operation. 
(After W. J. Mayo, Annals of Surgery.) 



steps. Sundry modifications of the procedure have 
been suggested or ma}^ recommend themselves to the 
individual operator, but the general plan outlined here 
is satisfactory. 

D. It now remains to restore the gastro-intestinal 



216 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

canal. Kocher's method of inserting the severed duo- 
denum into the posterior wall of the abbreviated stom- 
ach has been described, but it is preferable to make a 
gastro-jejunal anastomosis (Fig. 23\ It is usually easier 
and always satisfactory. Healthy tissues are being dealt 
with and there is no risk of tension. A sound and 
speedy healing with good functional results is to be 
expected. 

E. There are two forms of infection which must be 
guarded against ; direct cancer infection from the 
growth removed, and the ordinary pyogenic infection. 
Cancer infection occurs. It may be developed in the 
wounded viscera ; it lias been seen in the needle punc- 
tures of the abdominal wall even. In view of such 
possibilities Mayo recommends the Paquelin cautery 
for cutting through the duodenum and stomach. From 
our previous description it is seen that the greatest care 
is taken to guard against micro-organisms from the 
gastro-intestinal tract. The clamps, the careful gauze 
packing, the cautery, — all are important. Then, too, 
painstaking sponging of the whole field with wet com- 
presses is recommended, and drainage when there has 
been obvious soiling, — the use of a "cigarette drain," 
leading it out from behind the pocket above the trans- 
verse colon, taking pains not to bring it in contact with 
the crippled viscera ; it should emerge at the lower 
angle of the abdominal incision. 

Most important of all, however, for the avoidance of 
infection are those measures which we must use to an- 
ticipate and subdue 

F. Shock. — Although it is true that in simple uncom- 
plicated cases there is little or no shock, we must always 



CANCER OF THE STOMACH 217 

face these operations seriously. A patient is never truly 
sound who carries in his stomach ever so trifling a malig- 
nant growth. Such a patient usually has other condi- 
tions with which to contend, as Turck has pointed 
out. 1 There is likely to be a more or less profound 
cardio-vascular disturbance, anaemia, gastro-intestinal 
atony with resulting toxemia. To quote : " The latent 
cholemia or uremia, the general insufficiency of nor- 
mal metabolism or cellular inactivity, — these are the 
pathological conditions with which the surgeon is 
confronted." 

Bearing continually in mind, therefore, the probability 
of such complicating dangers, we must take our meas- 
ures. It is impossible absolutely to disinfect these stom- 
achs, but we may approximate to asepsis, and for two 
or three weeks, if possible, before operation we must 
turn our attention to local stomach cleansing and the 
building up, by proper foods, stimulants, and tonics, of 
the patient's general condition. Accustom him to the 
use of the stomach tube. Wash the stomach daily. 
Feed with an easily digested nitrogenous diet. If nec- 
essary, supplement this with nutrient enemata. Get 
water into the system. If the stomach fails to take 
care of water, give hypodermic or rectal infusions of 
salt solution, thirty ounces every twelve hours, for at 
least tw T o days before the operation. Have the patient 
well stimulated with nux vomica or strychnine. 

At the time of the operation one should give a hypo- 
dermic of morphine and atrophine before the anaesthetic 
and use a minimum amount of the anaesthetic, — prefer- 
ably ether, — and see to it that the anaesthetist is a man 

1 Fenton B. Turck, in Chicago Medical Recorder, June, 1903. 



218 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

of experience. Shock is sometimes sudden and profound 
during these operations. We have seen a patient die on 
the table under the hands of an inexperienced but over- 
confident anaesthetist. 

It is well to use strychnine if it is indicated during the 
operation, and a stimulating enema of six ounces of black 
coffee when the patient is put to bed. 

As for the after-treatment, — that is very simple. 
The patient's head and shoulders are raised on four or 
five pillows to take visceral pressure from the wounded 
organs, and so to promote healing. For two days rectal 
feeding is employed, though water by the mouth is 
given after twelve hours. On the third day regular 
liquid feeding by the mouth is begun cautiously, and 
is rapidly worked up until, at the end of ten days or 
even less, a fairly full diet may be allowed. The patient 
is out of bed in two weeks, and is encouraged to resume 
a more or less active life within the month. So much 
for the conduct of the operation itself. 

Let us now consider briefly what m$-results we may 
look for from such proceedings. In the first place, we 
present a few statistics of immediate results, — a partial 
list, but giving figures and illustrating what surgery has 
done during the past five years. It will be seen that 
there has been a fairly constant improvement. The 
dates are the dates of publication, though it is impos- 
sible to tell how far back into pioneer days some of the 
writers began the collection of their cases. 



CANCER OF THE STOMACH 



219 



GASTRECTOMIES 
Immediate Results 







Cases 


Deaths 


Mortality 
Pee Cent 


1900 


Robson .... 


572 


174 


30.4 


1900 


Hartmann 






20 


5 


25 


1901 


Carle and Fantino 






— 


— 


20 


1901 


Rydygier 






25 


17 


66 


1901 


Morison . 






16 


7 


45 


1902 


Kronlein 






50 


14 


28 


1902 


Mayos . 






28 


6 


21.4 


1903 


Murphy . 






14 


4 


28.6 


1903 


Kocher . 






24 


4 


16.6 


1903 


Krause . 






14 


4 


28.6 


1904 


Mayos 






13 


1 


7.7 


1904 


v. Mikulicz 






56 


26 


46.5 



Certainly that is a table interesting and suggestive. 
It indicates, if it indicates anything, that, with the 
exception of von Mikulicz, in the hands of the best 
surgeons the immediate mortality from partial gas- 
trectomy has fallen in five years from something in 
the neighborhood of 50 per cent to less than 30 per 
cent. In other words, with properly selected cases, the 
operation is not much more dangerous than an attack 
of pneumonia ; indeed, W. J. Mayo writes us that " gas- 
trectomy for cancer can be done with small mortality, 
and looked at even from the standpoint of relief is 
much better than gastro-enterostomy ; with a promise 
at least of cure, — so that we give the benefit of the 
doubt to gastrectomy." 

One hears the results of gastrectomy continually 
compared with the results of gastro-enterostomy. That 
is not a fair comparison. Gastrectomy is undoubtedly 
a more dangerous operation than is gastro-enterostomy, 



220 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

other things being equal. But other things are not 
equal. One operation removes a malignant disease 
and a foul focus. The other operation is for drain- 
age, but the foul focus is left. One is done, as a 
rule, in the early stages of the disease ; the other, in 
cases of advanced disease. Moreover, the mortality 
record of a given operator in cases of gastroenteros- 
tomy will be dependent largely on the chances he takes. 
Munro's figures in the subjoined table are an example. 
It appears from a study of his, cases that he pursued 
his operations to the end often in the face of desperate 
conditions. All of his cases were late ones. Often he 
would have done nothing more than explore had he not 
been enjoined by the patient to complete the operation 
at all risks. Little is gained by a comparison of figures, 
but we give here a few from the reports of the last five 
years. 

GASTROENTEROSTOMY FOR CANCER 



Cases 


Deaths 


40 


8 


23 


10 


24 


9 


74 


— 


30 


7 


107 


10 


29 


14 


18 


3 


21 


12 


29 


3 



Mortality 
Pee Cent 



1900 
1901 
1901 
1902 
1902 
1902 
1903 
1903 
1904 
1904 



Hartmann . 

Robson 

Carle and Fantino 

Kronlein 

Korte and Herzfeld 

Mayos . 

Krause . 

Murphy 

Munro . 

Robson 



20 
43.5 
37.5 
24.3 
23.3 
9 
48 
16.6 
57.1 
10 



Such being the figures, and death in a short time 
being inevitable, what is to be concluded as to the value 



CANCER OF THE STOMACH 221 

of this palliative operation ? From the statements of 
various reporters one sees that about half the patients 
die within a month, practically soon after the operation. 
A rare case may survive for two years, the average of 
the small remainder live less than six months. Accord- 
ing to their views of euthanasia, the opinions of surgeons 
vary. Says Munro, 1 " It is almost impossible that the 
discomfort from a rapid anastomosis can begin to ap- 
proach the suffering from starvation and vomiting ; on 
the contrary, the relief that so quickly follows, some- 
times within twenty-four hours, is one of the most 
gratifying experiences that the surgeon as well as the 
patient can enjoy." 

Quite another estimate is that of von Mikulicz, who 
says : 2 " The condition of the patient after gastro- 
enterostomy is often such that one cannot speak either 
of temporary cure or marked improvement. In view 
of the considerable number of patients who die within 
a few days after operation, and the still greater num- 
ber who live only a few weeks, one must conclude that 
gastroenterostomy for cancer of the stomach is an oper- 
ation of little value and one which is likely to be per- 
formed less and less often." 

Probably both are correct. It depends upon the side 
from which one approaches the shield. Combine the 
action of a wise and experienced surgeon with the 
expressed wishes of a thoroughly enlightened patient, 
and the surgeon will probably act correctly in any 
given case. 

That question of the wisdom of partial gastrectomy 

1 Boston Medical and Surgical Journal, August 11, 1904. 
* Von Bergmann's " Surgery," Vol. IV, p. 365, 



222 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

and of the value of the end-results obtained is beginning 
to assume a new aspect, — possibly a more hopeful 
aspect. With careful selection, a goodly number of 
patients survive the operation. Let us inquire now, 
from the scanty sources accessible, what may be the 
hope of such patients for relief, for comfort, for pro- 
longed life, and even for permanent recovery. 

These are Kronlein's figures : out of fifty excisions, 
fourteen died at once, leaving thirty-six to trace. Of 
those thirty-six "recoveries," twenty-three had recur- 
rence within the year, and died. Thirteen were living 
at the time of the report ; what their comfort may be 
is not known. 

These are von Mikulicz's figures : of one hundred 
excisions, thirty-seven died at once, leaving sixty-three 
to trace, — and fifty-eight were traced. Of these, thirty- 
eight had recurrences and died. Twenty were living at 
the time of the report. 

In other words, from those two clinics we learn that 
22 per cent lived from one to eight years. And von 
Mikulicz states of his that seventeen survived a year 
or more, ten more than two years, and four more than 
three and one-half years. Of those last four, none shows 
any sign of recurrence, so that they may be regarded 
as cured. Moreover, von Mikulicz tells us that of those 
who survived the operation, the average duration of life 
was more than sixteen months. 

In more fragmentary fashion here are a few state- 
ments from other surgeons, — most of them rather 
ancient statements. In 1898 Kronlein had had 
twenty-four cases with nineteen recoveries. Two 
were alive in their fourth year, while the average 



CANCER OF THE STOMACH 223 

duration of life for those who died had been sixteen 
months. 

In 1899 Maydl reported that the average duration of 
life for those who survived the operation was 11.7 
months. 

In 1898 Kocher published his interesting list of fifty- 
seven cases with fifty-two immediate recoveries and 
eight " cures," — alive between two and ten years after 
the operation. 

In 1899 Czerny reported twenty-nine cases with eigh- 
teen recoveries, and of the eighteen the average subse- 
quent duration of life was twenty-two months. 

Such are some of the figures from two to seven years 
old. Other men have encouraging statements to make, 
but at this writing there are few final reports. 

In August, 1904, W. J. Mayo stated to us that he and 
his brother had "six or seven cases more than two 
years ; one, three years ; and one, three years and seven 
months before death." 

Moynihan (in an exhaustive article in the Practitioner, 
December, 1903) gives some interesting figures gleaned 
from von Mikulicz's and Kronlein's reports on the sub- 
ject of gastric carcinoma : — 

Cases not operated upon, lived from first 

symptoms 

Explored cases, lived an average of . 
Gastroenterostomies, lived an average of . 
Gastrectomies, lived an average of . 

That is a fair summary of the situation, and the ques- 
tion returns again, What are we to do with this disease ? 
One may repeat the platitude that the diagnosis must 
be made earlier, in order to render operations effective. 



Kkonucin 


v. Mikulicz 


12.5 mo. 


11.5 mo. 


13.0 mo. 


14.3 mo. 


15.5 mo. 


14.0 mo. 


26.5 mo. 


24.5 mo. 



224 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

On the contrary, operations must be done to make the 
diagnosis. There seems no alternative to this dilemma 
at present. Middle age, with or without a long history 
of gastric disturbance, anorexia, distaste for meat, a 
craving for highly seasoned food, progressive emaciation, 
and debility, — these symptoms should make one very 
suspicious. Loss of gastric motility, vomiting, gnawing 
discomfort amounting to pain, — these come near being 
positive indications, even though no tumor be felt. As 
to that question of the presence of a tumor there has 
been much misconception. It has been said, and is still 
asserted, that the mere presence of a palpable tumor 
means disease so advanced as to contraindicate excision. 
From that statement we dissent. A small, hard tumor 
of the pylorus may be felt early, and if it is movable 
we should hope to perform a successful gastrectomy ; 
whereas an extensive tumor of the posterior pyloric 
region of the stomach may run its course without being 
obvious to the examining hand. 

Special consideration of complete gastrectomy has 
been purposely omitted in this chapter. That is an 
operation which is justifiable under the most unusual 
circumstances only. Thirteen cases have been reported 
at length, of which four died immediately. The rest 
lived from one to two years, and one possibly longer. 
We cannot learn that their lives were comfortable, and 
we do not feel that this operation ever will be regarded 
as more than a last desperate measure. 1 

1 Complete Removal of the Stomach (belated note). 

The following is taken from a review of Bockel's book, " De l'Abla- 
tion de l'Estomac, 1903." At the date of publication the number of 
cases reported was 48, and of these the result was unknown in 2. Of 



CANCER OF THE STOMACH 225 

Aside from the question of complete gastrectomy, 
however, we believe that cancer of the stomach, or sus- 
pected cancer of the stomach, should receive the sur- 
geon's consideration. As with appendicitis, disease of 
the bile passages, gastric ulcer, and other conditions 
which are now universally regarded as proper subjects 
for surgery, gastric cancer should have the benefit of a 
prompt surgical consultation. If a disease is ever a 
subject for operation, who is to determine when the 
exact moment has arrived ? The wise and experienced 
internist calls a surgeon the moment he suspects appendi- 
citis, — not necessarily for operation. The wise internist 
and the wise surgeon both appreciate that they must work 
constantly together. In the old days when the general 
practitioner was internist and surgeon in one, he might 
postpone such consultations indefinitely. To-day these 
two functions no longer rest with the same individual. 

If it is true that the experienced surgeon and the wise 
internist have their limitations and are interdependent, 
how much more true is it of the distant, overworked 
general practitioner and the surgeon ! Cancer is com- 
mon, one-third of all cancers are in the stomach, early 
exploration has a vanishing mortality, and in early ex- 
cision lies the only hope of cure. 

the remaining 46, 18 died and 28 recovered, giving a mortality of 39.1 
per cent. In 9 cases collapse was the cause of death, in 7 purulent peri- 
tonitis, and in one pneumonia. Seven of the 28 patients who have 
recovered are not available for a final report. Of the remaining 21, 11 
have died of recurrence after an interval varying between five months 
and five years; one died of intestinal obstruction without recurrence 
seven and a half months after the operation, and another in two years, 
of phthisis. Eight of the patients still enjoy the best of health. In the 
duodenum near the gastro-intestinal anastomosis a pouch forms which 
gradually dilates, and to a certain extent acts as a new stomach. Diges- 
tion goes on without disturbance, and there is a gain in weight. 



CHAPTER VIII 

THE BILE PASSAGES 

In a consideration of disease of the bile passages, 
there are two questions which present themselves at 
once : — 

(a\ Shall we operate f and 

(F) How shall we operate f 

To the first of these questions let us turn ourselves in 
this chapter, and to reach a conclusion in the matter let 
us take up some of the text-book details and make a 
study of conditions. 

At the outset we insist that much of the prevailing 
phraseology is misleading. Writers continually talk 
about disease of the gall-bladder and gall-stone disease, — 
phrases well enough so far as they go, but they do not 
tell the whole story. Even Mayo Robson, in the various 
editions of his well-known book, uses the title, " Gall- 
bladder and Bile-ducts." The classical word " cholelithi- 
asis" is equally misleading. We are discussing disease 
of the bile passages, of a system of passages. The gall- 
bladder is but a part of the system ; cholelithiasis is but 
one manifestation, though an important one, of the dis- 
ease. We have to deal with infection, inflammation, 
stone formation, suppuration, ulceration, cicatrization, 
stenosis, perforation, fistula formation, adhesions, peri- 
tonitis, local or general, malignant changes, and the 
involvement of other organs. 



THE BILE PASSAGES 227 

In viewing carefully this complex process, one sees 
that the confusing and involved, many-titled investiga- 
tion quickly resolves itself into the study of one broad, 
progressive, and far-reaching problem. 

The first and most important fact in connection with 
disease of the bile passages for the practitioner to ap- 
preciate is that the underlying cause is an infection : 
and the method of that infection is worth considering, 
— although, indeed, writers are not as yet altogether in 
accord as to what that method may be. Certain facts, 
however, are to be regarded as fairly well established : 
that the organism concerned is commonly the colon 
bacillus, though the bacillus typhosus is not infre- 
quently the offender ; and that the mode of entrance is 
either through the blood current or through the ducts, 
working upward from the intestine. The probability 
is that infection from the intestine is far the more com- 
mon method. C. A. Ewald, in a paper read before the 
Congress of American Physicians and Surgeons, at 
Washington, in May, 1903, said : " It is an established 
fact that our ideas concerning this disease have made 
marked fundamental changes during the last ten or 
fifteen years. We now know that this condition is due 
to a bacterial infection and not to the presence of gall- 
stones, the origin of which has always been more or less 
hypothetic." 

There seems to be no doubt that, in addition to an 
invasion of organisms, stagnation of bile is essential to 
gall-stone formation, and it is obvious that bacterial 
invasion, associated with swelling of the mucosa in the 
ducts, results in stagnation and a consequent precipita- 
tion of cholesterin from the involved epithelial cells. 



228 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Stones are formed from such a precipitate. These 
stones in their turn frequently act as an irritant to the 
mucosa lining the passages ; the irritated mucosa fur- 
nishes a suitable lodgement for pathogenic organisms ; 
further swelling, desquamation, and precipitation of 
cholesterin follow, and so we have established a vicious 
circle. For many years it was assumed that fresh bile 
in healthy subjects acts as an antiseptic. Recent ob- 
servations do not confirm this view. Fresh bile at 
the best is sterile, and some observers have found that 
it may act as a culture medium. Indeed, Ewald says 
that in the lower portion of the common duct the bacil- 
lus coli communis is commonly found, but that ordina- 
rily it is harmless there. 

It is agreed now that gall-stones arise from a catarrhal 
condition of the mucosa, associated with a swelling and 
desquamation of that membrane, and it is the fact of 
that catarrh, due to infection, upon which we must 
constantly fix our attention. 

That catarrh in itself is not always a trifling condition. 
It may cause severe symptoms, and it may go on to 
severer forms of inflammation without necessitating the 
formation of any stones, though it is fair to assume, 
from such knowledge as we have, that stone formation 
commonly is associated with the inflammatory process. 

In the lay mind, — indeed, in the minds of many 
physicians, — actual stones are the sine qua non of trouble 
in the bile passages ; and that impression has been the 
source of countless errors. We recall a case in which 
the diagnosis of " gall-stones " was made, on the strength 
of frequent long-continued attacks of boring pain in the 
right hypochondrium. Finally an operation was con- 



THE BILE PASSAGES 229 

sented to by the patient, when nothing was found but a 
thin-walled gall-bladder, containing bile-stained infected 
mucus, draining ineffectually through a partially ob- 
structed cystic duct. The patient and her family were 
chagrined that no stones were found, and were sceptical 
about possible benefit from the operation. However, 
the cholecystostomy which was done, followed by three 
weeks of drainage, relieved the congestion, freed the 
ducts, and resulted in a permanent cure. 

These infections of the bile passages do not commonly 
make any permanent impression on the hepatic and 
common ducts, for those structures are main channels 
and are subject to fairly constant natural drainage ; but 
when the inflammation spreads to the cystic duct and 
gall-bladder it finds conditions there very different 
anatomically, — conditions which seem designed to favor 
especially chronic inflammation and stasis, and stone 
formation. 

It is not the acute forms of infection that result finally 
in stone formation. The acute forms are ugly things ; 
they go on rapidly to suppuration, ulceration, and gan- 
grene even. It is the chronic, indolent catarrh that we 
look to as the important factor in the etiology of calculi. 

There is another term whose definition must be agreed 
upon in discussing these processes, — " cholangitis." 
The books are not in agreement. According to some, 
cholangitis is an acute infection of the bile passages 
within the liver, rare and fatal. According to others, it 
is an infrequent suppurative inflammation of the com- 
mon duct and radicles of the hepatic duct. Such con- 
ceptions are rather ancient and do not appear, to us, to 
express modern knowledge of infections of this region. 



230 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

We regard cholangitis as a not infrequent disease, and 
we see no reason for limiting the term to inflammation 
of a portion of the bile passages, nor do we regard it as 
indicating any particular degree of activity in the infec- 
tion. Cholangitis is an inflammation of the bile pas- 
sages, — localized or general, mild or virulent, acute or 
chronic, as the case may be, — and cholecystitis is but 
one manifestation of cholangitis. 1 

It does not seem necessary to quote further from our 
extensive notes to show how final are the conclusions of 
all competent modern observers that an infection is at 
the bottom of these diseases of the bile passages ; but 
we must content ourselves with repeating again the fact, 
which practitioners constantly should bear in mind, 
that between primary infection of the gall-ducts and the 
actual formation of stones there elapses often a period 
of time measured by months, and punctuated not infre- 
quently by a variety of symptoms. 

Catarrh of these passages does not differ essentially 
from catarrh of other passages lined with mucous mem- 
brane. There is the invasion of organisms, congestion, 
exudation, desquamation. 

With that picture in mind, it is well for a moment to 
give a thought to one feature of the anatomy, — the 
close relation of the common duct with the substance of 
the pancreas. Von Biingner of Hanau has lately pub- 
lished his observations upon the dissections of fifty- 
eight subjects, and notes that in fifty-five (nearly 95 per 
cent) the common duct passed through the substance of 
the pancreas. Only three times did it pass over the 
head of that organ. When it passes through the pan- 

1 Billings : " Cholangioitis, Inflammation of bile-ducts." 



THE BILE PASSAGES 231 

creas it is firmly imbedded in the gland tissue, and only 
with difficulty can it be dissected out. Furthermore, 
von Biingner observed that in one case only did the pan- 
creatic duct (duct of Wirsung) join the common duct 
in the substance of the gland. In the remaining fifty- 
seven cases the two ducts opened independently into 
the ampulla of Vater, within the substance of the wall 
of the duodenum. 

These two facts, thus recorded, have an important 
bearing on the pathology, as well as upon the operative 
treatment, of the diseases we are considering. The 
closely bound portion of the common duct within the 
pancreas is as inelastic almost as is the membranous 
urethra, and inflammation either within or without its 
lumen may readily lead to backing up, to stasis, and to 
jaundice. Stones will pass with difficulty through this 
constricted section, and the collections of mucus from 
the inflamed ducts above will also move through with 
difficulty, and painfully to the patient. Once past 
this portion, however, calculi find their next lodgement 
in the ampulla, with its narrow outlet into the intes- 
tine. They obstruct the pancreatic duct rarely, for, 
until the ampulla is reached, they do not commonly 
meet the pancreatic juice. Finally impacted in the 
ampulla, however, they plug the common outlet ; but, 
unless large, they lie below the separate openings of 
the common duct and the duct of Wirsung, allowing 
the discharges from those two passages to meet and 
mingle above them in the ampulla itself. So it comes 
about that with variations of pressure the bile may now 
be forced into the pancreatic passages, or again, the 
succus pancreaticus may flow up through the gall-ducts 



232 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

toward the liver. Opie has shown how this takes place, 
and it is one satisfactory explanation of the success of 
drainage of the pancreas undertaken through cholecys- 
tostomy. 

Authors tell us that the great majority of gall-stones 
form without the patient's knowledge of discomfort, 
and that often the discovery of their presence is made 
at autopsy only, or in the course of operation undertaken 
for some other lesion. For instance, Riedel says that 
only about 5 per cent of those afflicted with gall-stones 
ever have occasion to consult a physician on account of 
their presence, and this statement is repeated by most 
writers on the subject. 

From our own observations, we believe that such 
statements may be variously interpreted. The gall- 
stones, actually present as one result of the processes 
we have been discussing, may never have caused the 
typical pain or jaundice leading to their recognition, 
but other symptoms may have been present. We know 
that trouble in the bile passages is one of the common 
causes of digestive disorders, or that such trouble may 
be the result of processes in other organs giving rise to 
digestive disorders. The close anatomical association 
of the bile passages — especially of the gall-bladder — 
with the duodenum and stomach must not be forgotten, 
and internists, surgeons, and pathologists very well 
know that associated diseases of all these organs are 
common. Especially may one mistake duodenal ulcer 
for disease of the bile passages. 

Kaufmann 1 makes some interesting observations in 
this connection. He asserts that hyperacidity and hyper- 

1 American Medicine, p. 792, Nov. 14, 1903. 



THE BILE PASSAGES 233 

secretion of the stomach play a more important role in 
gall-stone formation than is generally thought, and that 
in the history of gall-stone cases he often finds that 
for years before the occurrence of the first severe colic 
patients have complained of milder disturbances such as 
commonly are attributed to gastric hyperacidity. He 
goes on to reason thus, and the quotation is illuminat- 
ing : " Since Naunyn's researches we have known that 
catarrh of the gall-bladder mucosa lays the foundation 
for the stones. This catarrh may be caused by a great 
many different disturbances of the abdominal organs. 
It stands to reason that hyperacidity of the stomach 
is particularly liable to lead to catarrh of the gall-blad- 
der. The highly acid stomach contents must irritate 
the mucous membrane of the duodenum in the same 
manner in which they irritate the mucous membrane 
of the stomach. Experiments, especially those made 
by Russian investigators (Pawlow), have demonstrated 
that highly acid stomach contents upon reaching the 
duodenum may cause spasm of the pylorus. It may, 
therefore, be assumed that spasm of the opening of the 
choledochus is brought about by the same cause. Both 
the constant irritation to the mucous membrane of the 
duodenum and frequent spasms of the opening of the 
choledochus may lead to chronic catarrh of the gall- 
ducts and thus to the formation of gall-stones. When 
gall-stones are already present, the irritation to the duo- 
denum by the acid stomach contents may bring on a 
gall-stone attack. In the interval between gall-stone 
attacks I have frequently seen symptoms of hyperacidity 
develop, which gradually increased in intensity, and were 
followed by a gall-stone attack." 



234 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

These remarks of Kaufmann are interesting for many- 
reasons. His assertion that gastric hyperacidity is fre- 
quently associated with gall-stone attacks corresponds 
with our own observations, and we will add the corol- 
lary that disease of the bile passages, with or without gall- 
stones, is often associated with gastric and duodenal ulcer. 
Which condition precedes the other is not always appar- 
ent, but it is certain that the two often are found 
together. 

The old assertion, already quoted, that of all the per- 
sons with gall-stones only five per cent know it, is mis- 
leading for other reasons. One opens an abdomen in 
the dissecting room, and finds gall-stones in the gall- 
bladder ; and one says, here is another case of unsus- 
pected gall-stones. In the name of Truth, how can one 
confirm such an assertion? Yet that is the sort of 
thing one hears constantly. Most of these dead bodies 
come from the almshouses ; probably no one knows their 
clinical histories. Again, as we must all admit, gall- 
stones and other bile-duct diseases may be, and fre- 
quently are, the source of grievous symptoms, attributed 
to disease of some other organ, — stomach, kidney, ap- 
pendix. Those old figures and assertions are of very 
little value, and the fact upon which we must constantly 
insist is that disease of the bile passages is far more 
common than usually is apprehended, and that long be- 
fore the stone formation has taken place or colics have 
occurred, one must be suspicious when hearing of such 
symptoms as discomfort, " all goneness," distress, ano- 
rexia, nausea, flatulence, constipation, malaise, malnutri- 
tion, continuous or frequently repeated and running over 
any considerable period of time. Such symptoms may 



THE BILE PASSAGES 235 

mean a variety of things, as we know, but very often 
indeed they mean trouble in the bile passages and are 
the precursors of the classical pain and icterus destined 
to follow. 

Tenderness will usually be found in the right hypo- 
chondrium, over the ducts, the gall-bladder, or at a point 
sometimes called "Robson's point," midway between 
the ninth costal margin, and the navel, if the bile pas- 
sages are at fault. 

We must not be understood to maintain that infec- 
tion and gall-stone formation may not take place with- 
out the patient's recognition of impaired health — for 
now we are encountering the personal equation, and 
statistics influenced by personal equations are constant 
lusus natures. 

We suggest merely the various conditions which 
may complicate gall-stones. The variety of lesions is 
very great, and the symptoms correspondingly intricate. 
Firm adhesions may form between the bile-ducts or gall- 
bladder and the duodenum, so that there results a pyloric 
stenosis with gastrectasis. This is a condition not infre- 
quently seen. When one finds a stomach dilated with- 
out obvious cause, he should look for a history and the 
physical signs of disease of the bile passages. 

Again, adhesions about these parts may be so numer- 
ous and dense that the stomach is held high up against 
the left lobe of the liver, which in turn may be drawn 
downward. 

Granted, now, that some sort of disturbance affecting 
the bile passages has begun, — the disturbance may be 
a simple primary catarrh or it may be an inflammation 
secondary to disease elsewhere, — how is one to know 



236 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

that there is trouble ? Why should one suspect it ? 
Does it progress insidiously, leaving the patient free 
from symptoms for months and years or even for a 
lifetime ? 

About all that, and in spite of armies of statistics, we 
can give no definite answer, and we never shall be able 
to do so. For who indeed may tell ? Certainly not armies 
of statistics. Until recently collectors of statistics were 
not concerning themselves with such elusive matters. 
Even now the inquiry is half-hearted or is neglected, 
and depends too largely for accuracy upon the personal 
equation of countless patients and numerous physi- 
cians. Moreover, we have yet much to learn about these 
diseases. Individual clinical experience and personal 
impressions must still be invoked largely, and though 
such sources of information are far from exact, they do 
furnish us with abundant food for thought. Take, for 
example, the partial experience of one of the writers of this 
book. Since his taking up this line of inquiry he has 
had to deal in private practice with twenty-four cases of 
operation for bile-duct disease. All of these persons 
have been cross-examined repeatedly and carefully. In 
not a single case was it certain that the final and con- 
vincing symptoms appeared suddenly and without pre- 
monition ; that is to say, those final symptoms which 
led immediately to the operation. To be sure, there 
was no uniformity in these histories, but in all the cases 
there had been some symptoms of faulty digestion run- 
ning often over many years. 

Here is one common symptom, — common, but sug- 
gestive : a small and quickly appeased appetite associ- 
ated with a tendency to corpulence. We have seen this 



THE BILE PASSAGES 237 

association in several cases, and have come to regard it 
as significant. There are usually other symptoms, — 
constipation, occasional distress after food, indefinite 
but sharp occasional pains in the upper part of the 
abdomen ; a bad taste in the mouth, furred tongue, 
sometimes nausea, frequent headaches, lack of vigor, 
exhaustion after slight exertion, diminished diaphoresis, 
high-colored urine, and frequent blurring of vision. 
Such patients will tell you that they are "bilious." 

When one has to deal with a " bilious " patient, he 
should bear in mind that the true condition may be an 
infection of the bile passages, and that the man may 
some day be seized with the classical symptoms of gall- 
stones ; indeed, the stones may even now be present. 
These bilious folk usually are victims of a defective 
metabolism. Their digestive processes frequently are 
at fault ; fermentations take place in their intestines 
and auto-infections result. They may be sufferers from 
sundry " neuralgic " or rheumatoid pains, — sciatica, 
lumbago, " stiff neck " ; they may experience attacks 
of arthritis. We used to call such things "rheumatic 
fever." These are the people to whom the old clini- 
cians assigned "diatheses." 

Of course, these symptoms may be present in vary- 
ing combinations and degrees in different patients. But 
what is the physician to do ? He should bear in mind, 
to begin with, that these are the cases cured commonly 
by internal treatment. Such patients are those who 
are suffering from lack of proper drainage of the bile 
passages, and to remedy that lack must be his first 
endeavor. 

In this discussion it is needless to dwell w extenso 



238 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

upon details of such treatment. Much of it is summed 
up in the word "Carlsbad": change of air and scene, 
recreation, a carefully regulated life, a restricted diet, 
exercise, massage, proper bathings, and the abundant 
drinking of saline waters. 

The effect of all this is obvious enough. The 
patient's general condition is improved, the systemic 
circulation is stimulated, and the affected parts are 
flushed. Hyperaemia is diminished, catarrh is relieved, 
local swelling subsides, normal drainage of the ducts is 
reestablished. In a few weeks the sufferer is well. 
With proper care and some attention to the conduct of 
his life after that, he may continue indefinitely in good 
health. 

Such, in brief, is the story of thousands of Carlsbad 
patients, — of the " bilious " and " rheumatic " who 
seek the Carlsbad treatment. But who may say that 
without such treatment they would not have lived to 
become the victims of gall-stones? And one must 
keep in mind always, in such cases, the reservation that 
gall-stones already may have formed, but have produced 
no diagnostic symptoms. 

There is another large and familiar class of cases, — 
those with gall-stones known to be present, but giving 
little trouble. Writers tell us that the great majority 
of gall-stone patients are not subjects for surgery. 
These are the patients who have given Carlsbad its 
fame. Of such cases countless " cures " are reported, 
but we must not let such talk stagger our intelligence. 
For here, again, what man positively may tell the facts ? 

We have discussed a class of cases, which, for con- 
venience, we have called the "bilious." From the 



THE BILE PASSAGES 239 

clinician's viewpoint they may differ from this second 
class of obvious gall-stone cases, but for the pathologist 
there is no sharp dividing line. Clinically, by treat- 
ment, the second class may be relegated to the first 
class, and a cure established ; but, as a fact, there is no 
evidence that any such " cure " has removed the stones. 
This consideration, however, must not lead us to con- 
sign all these mild gall-stone cases to the operating 
table. By the Carlsbad method, thousands may be 
relieved and enabled to lead comfortable lives. It is 
for the internist and the surgeon together to weigh 
each case and to decide upon the proper course. 

The effect of Carlsbad treatment in this second 
class of cases is quite similar to what it is in the first 
class. Inflammation is subdued, a condition more free 
from infection is gained, natural drainage of the pas- 
sages is secured. But the stones remain. Of that 
there can be no doubt in the vast majority of cases. 
Of course it is possible that, with the free opening of 
the ducts, small stones may escape and an anatomical 
cure result, but we have no evidence that this is a 
frequent outcome. Commonly, stones remain behind. 
They may lie there quiescent for years ; they may at 
any time prove a source of trouble. They are always 
infected, probably. 1 Perhaps it is best to leave them 
alone. Most patients think so, and many physicians. 

But there are recurrences of severe pain often after 
a cure is said to be established. What shall one do 
then ? Authorities differ about that question. It is 

1 " Terrier states that he has proved organisms (both B. Coli Commune 
and streptococci) to be present in all cases of inflammation of the bile 
passages." — " Gall-bladder and Bile-ducts," p. 83, Mayo Robson. 



240 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

our conviction that such cases should be treated like 
cases of chronic appendicitis, and that a radical opera- 
tion should be done. 1 

Very briefly let us consider some of the conditions for 
which we may be justified in passing by operation and 
resorting to internal treatment. 

If the attacks are mild and infrequent and there is 
complete latency between them, we may hope to get 
along without operation. These are the ideal cases for 
further Carlsbad treatment, and we may count with 
much confidence on prolonging health and comfort in- 
definitely by such a course. 

Then there are those cases such as Kaufmann and 
Ochsner describe, — cases with prominent gastric symp- 
toms with pronounced hyperacidity. Absolute rest of 
the stomach with frequent gastric lavage, followed by a 
course of Carlsbad, will often allay entirely the symp- 
toms. In such cases we have seen the benefit, in a 
number of instances, of the cold abdominal pack and 
large, high, cold enemata as advised by Pfaff. 

Another familiar condition in which operation may 
be avoided is that described by Kehr. In this the attack 
was an old one, quickly passed, and leaving no pain or 
tenderness in the gall-bladder region, but dyspepsia 
persisted. In such a case of course internal treatment is 
indicated. 

All reliable authorities are agreed that in an acute 
case, with complete occlusion of the common duct, it is 

1 Kehr says : " In many cases of stone in the latent stage, rest and 
alkaline treatment are effective. Especially in the recurring cholecystitis 
is the Carlsbad or Neuenahr water effective." He doubts, however, if 
often a permanent cure can be established by this method when stones 
are already formed. Such are Ewald's views also. 



THE BILE PASSAGES 241 

best to delay operation and employ medical treatment. 
If the condition persists, however, with the development 
of a systemic infection, we must operate. 

Then there are many cases of cholangitis, with or 
without a cholecystitis, in which it is well to rely for 
a time on medical treatment. By such means, when 
free natural drainage is established, the symptoms sub- 
side, and the patients may regain permanent health. 
Here, again, however, one must watch the case care- 
fully, prepared to operate and institute drainage through 
cholecystostomy if convalescence is delayed. 

Such, in general terms, are the cases in which we may 
avoid or delay operation. 1 They represent the great 
majority of diseases of the bile passages, and when we 
come to sum them up, what do they mean ? That 
most cases are mild ; that we have a first class in which 
there is no definite evidence of stones, a second class in 
which the infection and the stones give no great or 
constant trouble, and that in both of these classes we 
may avoid operation. 

There is a small third class of diseases of the bile 
passages in which operation must be our resort. This 
class is estimated variously as embracing from 5 to 
10 per cent of all cases of bile-passage disease, but it is 
the class which tries our resources. 

Writers have attempted to divide this class into 
" Calculous Diseases " and " Inflammatory Diseases.'' 
One cannot do that. We know that calculi are due to 
infections ; but who is to say always whether or not, in 
a given case, calculi complicate an infection ? The 

1 There is no convincing evidence that drugs dissolve calculi. Deep 
massage of gall-stones is dangerous. 



242 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

difficulties of an accurate anatomical diagnosis before 
opening the abdomen are insuperable, consequently the 
text-book summing up of pathological conditions which 
demand operation is often clinically impossible. We 
can, however, in somewhat general terms discuss briefly 
the problem and attempt to say what should be done 
in any given case. 

Mayo Robson gives seventeen reasons for operating 
on the bile passages. 1 Some of these reasons overlap 
each other, but quite fully they cover the ground. They 
may with advantage be condensed into three groups. 
There is, first, that type with " frequently recurring 
biliary colic without jaundice, with or without en- 
largement of the gall-bladder." That is the condition 
probably for which most commonly we operate, but it 
is not always easy to distinguish this from that con- 
dition described above for which we send the patient to 
Carlsbad. The difference is one of degree only, and it 
is especially in the consideration of such cases that 
experience counts. In general terms, if such a case 
is mild, and the man is holding his own, try Carlsbad ; 
if he is failing, operate. 

If a patient has an attack of pain followed by jaun- 
dice, and then recurring pains, look for stone in the 
common duct, and operate. The above two conditions 
are common. They deal obviously with stones. 

In a second operative class is a group of cases in which 
the vnfiammatory symptoms are the more apparent. 
Mayo Robson says operate " in enlargement of the gall- 
bladder without jaundice, even if unaccompanied by 
great pain." That means usually that we are dealing 

1 " Gall-bladder and Bile-ducts," pp. 243-244 (third edition). 



THE BILE PASSAGES 243 

with some form of obstruction to the cystic duct. It 
may mean empyema of the gall-bladder. 

When we suspect a phlegmonous cholecystitis or 
gangrene, a rupture of the gall-bladder, or an infective 
or suppurative process with constitutional symptoms, 
we must operate. 

In the third place, there are those symptoms pointing 
to an involvement of other organs or of the tissues 
outside the bile passages. Again we must operate, — 
in peritonitis starting in the right hypochondrium ; in 
the case of localized abscess ; to relieve painful adhe- 
sions and to cure the various fistulse which may have 
formed. 

Of course, traumatic lesions, stabs, or shot-wounds 
in the right hypochondrium must be explored and 
repaired. 

Primary tumors of the gall-bladder region, provided 
there be no metastasis, must be removed. 

And diseases of the pancreas secondary to disease of 
the bile passages must be treated by appropriate opera- 
tive measures. 

Such are the leading indications for operation. The 
conditions may appear clean-cut or they may be obscure. 
Often they are extremely complicated ; nearly always 
they mean disease of long standing. Often they pre- 
sent technical problems of extreme difficulty which call 
for the greatest ingenuity in their solving. They are 
never lightly or unadvisedly to be undertaken, and they 
carry with them the familiar old surgical lesson of 
neglected opportunities. The details of such operations 
we will discuss in the next chapter. 

Cancer of the bile passages is not uncommon. Let 



244 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

us give it some serious thought here. That traumatism 
has a definite place in the etiology of malignant disease 
most observers are agreed. In so far we have returned 
to the beliefs of the old masters. The relation of cancer 
to gall-stone disease appears to be as frequent and as 
close as to chronic gastric ulcer. So here, again, we 
have an interesting interdependence or correlation of 
conditions. Inflammations of the bile passages are 
found associated with duodenal and gastric ulcer. Such 
ulcers are frequently the forerunners of malignant 
disease, and gall-stones are found associated with cancer 
of the gall-bladder, liver, stomach, and pancreas, while 
all these structures and conditions, so closely related, 
centre about the duodenum, as we have pointed out. 

Be van alone, among authorities on this subject, ques- 
tions the dependence of gall-bladder cancer upon calculi, 
for he says that he has seen little evidence pointing to 
gall-stones as a factor in producing cancer. 

Conversely, W. J. Mayo's observations are interesting : 
out of five hundred and thirty-four cases of bile-passage 
disease he found cancer in twenty-four, or more than 
4 per cent, and he goes on to say, "As the presence 
of gall-stones occurs in only 15 per cent of secondary 
cancers of the gall-bladder, and in over 90 per cent of 
primary cancers, we must conclude that they are the 
chief etiological factor in the production of malignant 
disease of the organ." He remarks, further, that gall- 
stones are present in nearly all cancer cases, though the 
stones may have been quiescent for years. 

Other writers have found the proportion of cancer in 
bile-passage diseases to be much higher than Mayo's 
4 per cent. J. T. Rogers, writing in the St. Paul Medical 



THE BILE PASSAGES 245 

Journal? says that malignant disease occurs in about 
10 per cent of the cases, and observes that primary 
malignant disease of the gall-bladder is not the rare 
condition it was once supposed to be, and that the pres- 
ence of gall-stones predisposes the patient to malignancy. 
He states very truly, also, that the diagnosis of early 
cancer is almost impossible, " but if we are constantly 
on the lookout, and realize that according to Schroder 
14 per cent of the gall-stone cases suffer at one time 
from cancer of the biliary passages, and Naunyn believes 
that half the cases of chronic jaundice diagnosticated as 
cholelithiasis are complicated with cancer, or are due 
to cancer alone, the diagnosis can oftener be made." 
Kehr, Robson, Ewald, Musser, and Hoppe-Seyler bear 
similar testimony. 

The purpose of this argument is to urge the wisdom 
of operation in established and persistent disease of the 
bile passages, on account of the chances (fourteen (?) in 
one hundred) of later malignant development. 

As for the diagnosis of cancer of the bile passages, 
that is quite another matter, — usually very difficult. 
The problem is similar to that of gastric cancer. One 
can rarely make a diagnosis of primary gall-bladder 
cancer early enough successfully to remove the growth ; 
therefore, shall one not explore early for diagnosis ? 

As one may not expect to make an early diagnosis of 
cancer of the bile passages, what is one to do ? In the 
first place, bear in mind always the considerable prob- 
ability that cancer may develop in any case of disease 
of the bile passages. If relief from symptoms and a 
return to health are not secured after two months of 
1 Volume for 1903, p. 828. 



246 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Carlsbad treatment, exploratory operation should be 
performed. Obstinate slight jaundice should arouse 
suspicion, and with this jaundice there may be no 
pain associated — or there may be constant, slight, or 
gnawing pain, but no colic. A hard tumor of the gall- 
bladder, when felt, may confirm the diagnosis of can- 
cer ; but it must also confirm the belief that it is too 
late to save the patient's life by operation. A common 
source of error lies in the possible presence of a mass 
of inflamed viscera matted into a tumor. 

There is a sign of considerable importance, however, 
— a gall-bladder enlarged by retained fluid, perma- 
nently enlarged, not transiently. This is a condition 
frequently misinterpreted. Courvoisier explained it. 1 
R. C. Cabot summarizes his observations as follows: 
" When the common duct is obstructed by a stone, dila- 
tation of the gall-bladder is rare. When the common 
duct is obstructed by other causes, dilatation of the gall- 
bladder is common." Mayo Robson puts the case in 
these words : " Jaundice with distended gall-bladder is 
presumptive evidence in favor of malignant disease ; 
but jaundice without distended gall-bladder favors the 
diagnosis of cholelithiasis." 

The explanation of such well-recognized facts is ob- 
vious enough. Every surgeon experienced in these 
operations knows that stones rarely plug completely 
and permanently the common duct, for the duct be 
comes greatly distended, as a rule, and stones move 
about in it, — the " floaters " described by Fenger. 
With cancer the duct is permanently and continuously 

1 See an interesting essay on " Courvoisier's Law," by R. C. Cabot, 

The Medical News, Nov. 30, 1901. 



THE BILE PASSAGES 247 

obstructed. Whether or not cancer is present, there 
may be an inflamed and thickened gall-bladder, incapa- 
ble of distention, in which case Courvoisier's law 
would fail to become operative. In other words, for 
the successful working of the law we must presup- 
pose a comparatively normal gall-bladder, — a con- 
dition by no means always present. The law is 
interesting and valuable, however we must discount 
its negative evidence ; but its positive evidence — a 
permanently enlarged cystic gall-bladder — is of great 
value. 

Further evidence in making our diagnosis of cancer is 
cachexia and the progressive general symptoms common 
to all malignant disease. 

Cancer of the bile passages secondary to cancer of the 
stomach and other organs is a common affliction, and 
a possibility always to be recognized by the surgeon ; 
but its consideration need not detain us here. Opera- 
tive measures for its removal must be futile. Opera- 
tion for the relief of symptoms, for drainage, and for 
anastomosis may occasionally be justifiable, and with 
such procedures we will deal later. 

Up to this point our discussion has led us to the 
following conclusions : — 

(V) Disease of the bile passages begins with inflam- 
mation, and leads to tissue changes as well as to the 
formation of gall-stones. 

(5) The great majority of diseases of the bile passages 
may be relieved or apparently cured by internal treat- 
ment. 

(<?) A small number of cases (10 per cent ?) do not 
recover under internal treatment ; but, owing to ex- 



248 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

tensive tissue changes and the permanent lodgement 
of gall-stones, require operation. 

(cT\ Malignant disease is a common result or com- 
plication of disease of the bile passages. The possibility 
of its development should be borne in mind constantly, 
and more frequent early operations should be done with 
a view to anticipating its development. 

In the next chapter we shall consider the various 
operations upon the bile passages. 






CHAPTER IX 

SURGERY OF THE BILE PASSAGES 

When one considers the question of how to operate 
in disease of the bile passages, one finds in the analysis 
of cases and the experience of many operators that 
certain clearly defined and fundamental principles be- 
come salient, — principles as old as surgery. These 
biliary diseases are infectious in their origin, and in 
operative treatment one must employ the sound and 
ancient maxims applicable to the treatment of all 
infections. In dealing with a carbuncle or a palmar 
abscess, one removes the offending material and drains 
the parts ; he drains until all possibility of reinfection 
has been eliminated. 

In applying those same sound principles to infection 
of the bile tracts, it is possible to meet all the problems 
of this often obscure and much debated subject by 
formulating and observing the following three rules : — 

1. Remove stones. 

2. Remove, so far as possible, all disorganized, de- 
generated, and permanently crippled tissue. 

3. Drain. 

In special cases, of course, the intelligence of the 
surgeon may prompt him to modify or depart from 
these rules. The condition of the patient may not 
permit of a radical operation at one sitting ; malignant 
involvement of the parts may render impossible com- 

249 



250 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

plete removal of the disease; extensive adhesions and 
associated, complicating disease of other organs may- 
prohibit more than palliative measures, — but always one 
should keep in mind and aim to observe those three 
cardinal rules. 

The thought of operative treatment for gall-stones is 
nothing new. We must credit Dobbs, Sims, and Kocher 
with the pioneer work in modern surgery of the bile 
passages, but it is only within the last ten years that 
definite progress has been made and an intelligent 
technique evolved out of countless operations and a 
multitude of writings. 1 

At present the debate, such as it is, centres around 
the questions : when shall we operate ? shall we remove 
the gall-bladder or drain it ? shall we remove stones 
whenever present ? shall we drain the hepatic duct ? 
shall we ever omit drainage of the operative field ? how 
shall we avoid hernia ? 

That question, when to operate, has been discussed at 
some length in the previous chapter. Let us then turn 
to a consideration of the other leading questions. 

The discussion of choleeystostomy and cholecystectomy 
was waged for a number of years, and a multitude of 
papers bearing on the subject may still be read with 
interest and profit. Enthusiasm almost to the verge of 
acrimony was displayed at times, and the points of view 

1 " The surgical treatment of gall-stones was inaugurated by Sharp 
and Monaud (according to Gottfried Miiller and Petit). Bloch, in 1774, 
proposed the artificial formation of adhesions in the region of the gall- 
bladder. Chopart and De'sault, F. A. Walter, and Richter improved 
these methods. Herlin, L'Anglas, and Duchainois studied the ligation 
of the cystic duct and the incision and extirpation of the gall-bladder as 
early as 1767." — Hoppe-Seyler in Nothnagel's " Encyclopedia," " Diseases 
of the Liver," p. 530. 



SURGERY OF THE BILE PASSAGES 251 

of sundry writers often were so divergent that it seems 
as though their premises were too dissimilar to admit 
of arriving at the same conclusions. Starting with the 
proposition that cholecystostomy is simple, safe, and 
easy, the advocates of that procedure wished to apply 
the principle practically to all operations on the bile 
passages ; while those who favored cholecystectomy 
averred that the gall-bladder is analogous to the ap- 
pendix, and that, when involved in disease, it should 
always be removed. 

We have now learned that there is a distinct place 
for both operations, though at times, in a given case, 
the conditions are so intricate and the indications so 
overlap each other that it may be difficult for the expe- 
rienced surgeon even to be sure of which procedure to 
follow. 

Owing to such uncertainty in past years, uncertainty 
leading often to blind groping, the statistical results of 
much of the surgery of these parts were extremely 
variable, — often surprisingly good, often shockingly 
bad. To-day, with the great experience which every 
large surgical clinic can furnish, it seems incredible that 
results so bad as were known a few years ago ever 
could have been condoned. That is beside the mark. 
Only by the struggles through which former operators 
passed have we been able to reach our present more 
sound and intelligent position. 

Statistics of sundry operators are unsatisfactory also, 
for we lose the personal equation. The statistics of an 
operator of six or seven years ago may not in fairness 
be compared with the statistics of the same operator, or 
even of a younger operator, of to-day, and the desperate 



252 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

chances taken by one man may be shirked or wisely 
avoided by another. 

Not long ago F. Winslow of Boston collected into 
a valuable paper, as yet unpublished, the statistics of 
operations on the bile passages performed by a vari- 
ety of surgeons at the Massachusetts General Hospital. 
Beginning with the year 1894 he traced the histories 
with the end-results of three hundred cases. Many of 
these operations were done in the early days, and if one 
were to study their records, one would find much to cen- 
sure. During most of that time, when it came to deal- 
ing with the gall-bladder, cholecystostomy was the 
favorite operation. There were nearly four times as 
many cholecystostomies as cholecystectomies. Without 
a knowledge of actual conditions in individual cases, a 
comparison of figures and an estimate of the value of 
any operation is futile ; nevertheless, the following fig- 
ures have their interest : — 

WINSLOW'S FIGURES 





OHO LECYST08TOMIE8 


Cholecystectomies 


Total cases 


170 


44 


Traced cases s 


128 


38 


Good results 


46-35.9% 


25-66.9% 


Poor results ...... 


59-45.6% 


4-10.5% 


Deaths 


23-17.9% 


9-23.6% 


Hernias 


4- 3.1% 






Contrast that table with the later statistics (of the 
Mayo brothers) published in 1903. W. J. Mayo 1 reports 
three hundred and forty-two cholecystostomies with eight 
deaths, a mortality of 2.3 per cent ; and sixty-six chole- 

1 Boston Medical and Surgical Journal, Vol. CXLVIII, p. 545, 1903. 



SURGERY OF THE BILE PASSAGES 253 

cystectomies with two deaths, a mortality of 3.03 per 
cent. His " mortality " shows a great improvement 
over Winslow's figures, but it is interesting that the 
percentage of deaths following the two operations — 
cholecystostomy and cholecystectomy — respectively is 
in about the same ratio in both sets of statistics. 

In that paper of his, Mayo does not deal with the 
question of end-results, so that we are unable to make 
an extensive comparison of the subsequent histories in 
the two sets of cases. Mayo's death-rate however is so 
greatly lower than that recorded at the Massachusetts 
General Hospital that we must assume for it some cause 
other than unsatisfactory pioneer work in the latter case. 
One salient cause for Mayo's better showing is probably 
the fact that competent operators in their private clinics 
can make a better choice of material and are likely to 
encounter fewer desperate cases than fall to the lot of 
surgeons doing routine work in a great municipal hospi- 
tal. As a matter of fact, from inquiries among surgeons 
of the Massachusetts General Hospital staff, we find that 
their experience in private operating shows a mortality 
markedly lower than the hospital mortality. 

Other writers give a mortality so variable for these 
two operations of cholecystostomy and cholecystectomy 
that it is difficult to make any comparison between 
clinics. We can say that complicated operations give a 
high mortality in the hands of all surgeons ; that simple 
operations give a low mortality ; that the mortality 
when cholecystectomy has to be done is slightly higher 
than when cholecystostomy is done, because condi- 
tions necessitating the former operation are the graver ; 
and that the statistics of all surgeons are improving 



254 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 



with increased experience, a better appreciation of indi- 
cations, and an improved technique. 

Here is a short table showing the results of sundry 
men. It is arranged chronologically. 









Choleoystostomie 8 




Cholecystectomies 






Mortality 


Mortality 


1890 


Courvoisier . 


21.14% 


1890 


25.5 % 


1893 


Martig • 




17 % 


1894 


17.24% 


1896 


Kehr . 




6 % 


1894 


5 % 


1900 


Delageniere 







1900 


23 % 


1901 


Terrier . 







1901 


25 % 


1902 


Kehr . 




2-1 % 


1902 


1.1 % 


1904 


Rob son 




2.7 % 


1904 


6.2 % 



After reading such a set of figures, one thinks he sees 
very convincing facts, but when he comes to analyze 
the reports he despairs of statistics ; for then he observes 
at once — indeed, the reporters distinctly state — that 
here are various types of disease, some indiscriminately 
mingled, some carefully separated. Take, for instance, 
those figures attributed to Kehr in 1902 : Stern, Kehr's 
pupil, tells us that Kehr had two hundred and thirty- 
seven 'cystostomies with five deaths, — a mortality of 2.1 
per cent ; while Robson quotes Kehr, " but the compli- 
cated cases, including malignant disease, had a mortality 
of 97 per cent." Robson concludes, " Cholecystectomy 
has hitherto undoubtedly been a more serious operation 
than cholecystotomy [cholecystostomy], but since the 
method of complete exposure of the operation area has 
been adopted, it has been rendered both easier and 
safer." 

As we have insisted, such a statement as that last 
of Robson is open to endless discussion, for safety 



SURGERY OF THE BILE PASSAGES 255 

and ease depend on the conditions presented by in- 
dividual cases. At any rate all the figures at hand 
seem to prove that such cases as have been submitted 
to cholecystostomy show a slightly lower mortality 
(dependent again on the severity of conditions present) 
than do the cases treated by cholecystectomy. 

A fact more interesting and significant than that of 
mortality is the permanence of cure. Winslow's figures 
give us information on end-results, and his findings 
resemble those given in Robson's latest elaborate 
tables. Winslow found that of the cholecystostomies 
35.9 per cent showed good results, while 45.6 per cent 
showed poor results. On the other hand, of the chole- 
cystectomies, 66.9 per cent were permanently cured, 
and only 10.5 per cent had recurrences, or continued 
to suffer. It should be recognized, however, that " poor 
result " is a flexible term, and that many of those un- 
fortunate ones were much better off than before opera- 
tion, — whether 'cystostomy or 'cystectomy was done. 

Bearing in mind, now, our three cardinal rules, let us 
see how we can apply them in given cases, — as to the 
choice of 'cystostomy or 'cystectomy. 

If we find no damage to structure, our indications 
are plain enough : drain the gall-bladder. The various 
writers on the subject have formulated their ideas 
regarding the indications for 'cystostomy, and the evi- 
dence is convincing that there are three classes of cases 
in which that operation generally is indicated : — 

(a) When the gall-bladder and ducts, though contain 
ing stones, are not crippled by the inflammatory process. 

(5) When acute inflammatory processes exist, with 
or without the presence of stones, 



256 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

(c) When the common duct is obstructed by unre- 
movable malignant disease. 

As an example of class (a), we may take the familiar 
one, a freely movable, normal-appearing gall-bladder, 
full of faceted stones — the cystic duct free or con- 
taining only small movable stones. In such cases re- 
moval of the stones, followed by drainage, will result 
surely in restoring the parts to the normal. 

Sometimes, rarely, when the patient is too exhausted 
to endure a long, severe operation, a 'cystostomy pre- 
liminary to 'cystectomy may be unavoidable. 

Class (5) furnishes a great variety of cases suitable for 
'cystostomies. It is a complicated class. While class (#) 
deals with the simplest of stone cases, we may call class 
(5) the inflammation class. 

In empyema of the gall-bladder, without disorganiza- 
tion of that viscus, 'cystostomy is indicated ; also 

In certain cases of chronic catarrh of the gall-bladder 
or bile ducts, 1 

In infective cholangitis, 

In obstruction by hydatids, 

In hydrops of the gall-bladder (not due to stricture 
of the cystic duct), 

In some cases of phlegmonous cholecystitis accompa- 
nied by great prostration. 

The conditions just described call for 'cystostomy be- 
cause serious infections demand imperatively thorough 
drainage, with the minimum of risk to the surrounding 
parts. 

As for class (<?), it must be obvious that with an obstruc- 
tive jaundice due to tumor occluding the ducts a 'cys- 

1 Robson. 



SURGERY OF THE BILE PASSAGES 257 

tostomy, or sometimes a 'cystenterostomy, is essential 
for permanent biliary drainage. 

Except in the case of malignant disease, cholecystos- 
tomy, done for the conditions described above, gives a 
low mortality and a large proportion of permanent cures. 
Such are the conditions for which experienced surgeons 
are now doing the operation, the effect of which is that 
by observing our first and third cardinal rules the parts 
are restored to their normal condition, and interrupted 
function is resumed. 

When we come to the indications for cholecystectomy, 
our course is by no means always so safe and easy. There 
are two conspicuous indications for that operation : — 

Class (77) Disease crippling the cystic duct. 

Class (V) Disease crippling the gall-bladder. 

These two conditions — (7?) and (Y) — often are inter- 
dependent, often are present together. We are now 
within that field of extensive associated lesions which 
furnishes the text upon which this book is built. When 
the gall-bladder is inflamed, thickened, ulcerated, ne- 
crotic, disorganized, we must expect and look for exten- 
sive disease, — erosions and stricture of the cystic duct ; 
inflammation and dilation of the hepatic and common 
ducts ; sometimes adhesions and ulcerations, with fistulse 
into neighboring organs ; obstruction at the ampulla of 
Vater with involvement of the pancreas in the general 
inflammatory process ; even disease of the liver and at 
times duodenal ulcer, gastric ulcer, pyloric obstruction, 
and eventually cancer, as the result of the long-continued 
disease. 

Such are the conditions calling for the application of 
all three of our cardinal rules, and especially of rule 



258 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

two, " Remove, so far as possible, all disorganized, 
degenerated, and permanently crippled tissue." That 
means 'cystectomy. A diseased gall-bladder, thickened, 
inelastic, ulcerated, adherent, contracted, is functionally 
useless ; it may remain a nidus of infection. 

Serious damage to the cystic duct, even if other 
parts are unimpaired, renders the gall-bladder relatively 
useless. 

Ulceration of the duct means cicatrices, kinks, 
twists, stricture, occlusion often, with hydrops of the 
gall-bladder, or chronic catarrh and future destructive 
processes. 

So with damage to " cysticus " or gall-bladder, 'cys- 
tectomy is essential ; 'cystostomy would result only in 
palliation and future trouble. 

As examples of class (cty we may have stricture of the 
cystic duct, 

Mucous fistula, due to stricture of the cystic duct, 

Hydrops of the gall-bladder, due to stricture of the 
cystic duct, and certain other cases in which the gall- 
bladder is very much dilated. 

As for class (V), in that are to be found the manifold 
conditions involving structural damage to the gall-blad- 
der. With or without the presence of stones, — for 
stones often are an incident merely in the course of the 
disease, — we may find phlegmonous cholecystitis and 
gangrene of the gall-bladder. In class (e) we may find 
also 

Multiple and sometimes perforating ulcers, 

Chronic cholecystitis with contracted gall-bladder, or 
possibly a gall-bladder enlarged, thickened, ulcerated, 
while the common duct is unobstructed, There are, too. 



SURGERY OF THE BILE PASSAGES 259 

Those cases of empyema of the gall-bladder in which 
there is serious damage to structure, 

Cancer or other tumors limited to the gall-bladder, 
and 

Calcareous gall-bladder. 

We shall have a few words to say, shortly, about the 
method of removing the gall-bladder ; but here and now 
we insist upon the essential importance of drainage in 
all operations upon the bile passages. The surgeon is 
dealing with an infection, and he can never be certain 
that with the tying off of the cystic duct some leakage 
may not take place. A rubber tube rolled in gauze or 
otherwise protected by gauze always should be sewed 
with catgut into the stump of the duct. 

The two operations — of cholecystostomy and chole- 
cj^stectomy — are by far the commonest which the sur- 
geon must employ in dealing with the bile passages ; 
but there are others. 

Cholecystendysis is an antiquated procedure. It used 
to be called " the ideal operation." It consisted in a 
preliminary cholecystostomy, then in sewing up the open- 
ing in the gall-bladder, dropping it back or anchoring 
it to the abdominal wall, and closing the external 
wound. Sometimes the gall-bladder leaked, and the 
patient died of peritonitis. No one does cholecysten- 
dysis nowadays. 

Choledochotomy and choledocholithotomy are words 
sometimes used by writers. Obviously they mean 
opening the common duct and removing stones. The 
manoeuvre is given the dignity of a little historical 
sketch by Robson, and is ranked as a distinct operation. 
Before the development of latter-day technique it de- 



260 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

served to be so ranked ; but it is common enough at the 
present time, and is now merely a detail in the general 
operation of clearing the bile passages. 

Cholecystenter ostomy is what its name implies. An 
opening is made between the gall-bladder and the 
bowel, — duodenum, jejunum, or colon. The operation 
is employed when bile is unable to reach the duodenum, 
owing to irremovable obstruction in the common duct. 
A sound gall-bladder is needed to insure success. 

The indications for the operation must be obvious to 
any one familiar with the mechanics of the situation. 
Robson gives the following rules : — 

Cholecystenterostomy is indicated, — 

" 1. In biliary fistulse depending on stricture in, or 
other permanent occlusion of, the common duct. 

" 2. Very occasionally in cancer of the head of the 
pancreas, or malignant tumor of the common duct. . . . 

" 3. Very occasionally in impaction of gall-stones in 
the ducts, where the common bile-duct cannot be freely 
exposed and the patient is not in a fit condition to bear 
the more prolonged operation. . . ." 

Obviously, contraindications are : — 

" 1. In any obstruction of the bile-ducts which can 
be cleared away with any reasonable probability of 
success. 

" 2. In malignant disease of the head of the pancreas 
or common bile-duct leading to distention of the gall- 
bladder, the mortality is so great that it is hardly 
worth incurring the risk, unless the patient be in a very 
good condition. 

" 3. In contracted gall-bladder, where it is impracti- 
cable to insert the button or bobbin. 



SURGERY OF THE BILE PASSAGES 261 

" 4. In very large gall-bladder, with obstruction of 
the cystic duct, when cholecystectomy should be 
done." 

Choledochenterostomy is, of course, a substitute for 
cholecystenterostomy. It is done for much the same 
conditions. When the gall-bladder itself, owing to 
impairment of structure, cannot be utilized, the anas- 
tomosis is made between the common duct and the 
bowel. 

Earlier in this chapter we stated that we should con- 
sider the question of whether or not to remove all 
stones whensoever found, of drainage of the hepatic 
duct, the omission of all drainage at times, and the 
question of avoidance of hernia. Such matters will be 
discussed in the following paragraphs, but in connec- 
tion with the broad general subject of technique. The 
method of approaching and conducting operations on 
the bile passages is a subject of historical as well as 
immediate interest ; and if one had the time and 
patience, the tale would prove an attractive study. 
Literature on the subject is enormous ; a mere enu- 
meration of the writers would fill several of our pages. 
The names of a few of the older authors have been 
mentioned ; while to-day we hear most frequently of 
Beck, Bevan, Brewer, Cushing, Da Costa, Fenger, Franke, 
Halsted, Kehr, Lejars, Marti g, Mayo, Mixter, Moynihan, 
Richardson, Riedel, Robson, Schroder, Terrier, Weir, and 
Witzel. 

Not long ago Howard Lilienthal 1 published an excel- 
lent modern description of cholecystectomy, — a de- 

1 Annals of Surgery, July, 1904. 



262 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

scription which does not differ essentially from that now 
given by many surgeons. It is difficult here to avoid 
plagiarism. Let us take up first a variety of considera- 
tions dealing with the broad subject of operations on the 
bile passages : the preparation of the patient, instru- 
ments, and sponges, the question of bleeding in jaun- 
diced patients, the position of the patient during 
operation, the character of the incision, the exposure 
of the passages, the method of draining the gall-bladder, 
the method of removing the gall-bladder, opening and 
treating the ducts, methods of reaching the ampulla, 
complications, pancreatic disease, pyloric disease, the 
management of tumors. 

The question of preparing the patient presents one 
or two points of special interest. It is needless to dilate 
upon the ordinary details of preparing the room, the 
skin, etc., but attention should be paid to care in 
anaesthesia, to stimulation, and to avoidance of hemor- 
rhage. Many of these patients are very ill, exhausted 
by pain and starvation ; the anaesthetist should be 
specially skilled. 

Stimulation should be begun at least twenty-four 
hours previous to the operation. We know of nothing 
better than strychnine, gr. -^ every four or six hours. 
An infusion of normal salt solution, after anaesthesia 
is complete, is important if the patient is feeble ; and 
the stomach should be washed out with sterile salt solu- 
tion half an hour before the operation, when there is any 
question of gastric or duodenal complications. 

Dealing with haemophilia, especially when there is 
jaundice present, is important. If disease of the pas- 
sages is of long standing and jaundice is chronic, 



SURGERY OF THE BILE PASSAGES 263 

there is decided danger of obstinate, oozing, capillary 
hemorrhage. This is especially true when the pancreas 
is found involved during the operation. To obviate the 
danger of bleeding, various methods and remedies have 
been employed. Of these there is good reason to be- 
lieve that calcium chloride is one of the most effective. 
We have found it so in our own experience, while it 
is recommended as a routine by Robson, who quotes 
with approval the work and reports of Wright (.Brit- 
ish Medical Journal, Dec. 18, 1891) and of Bertignon 
(Medical Press, Nov. 23, 1902). We have followed 
Robson's method and agree with him that large and 
repeated doses are required in order to obtain good 
results, — calcium chloride in 30-grain doses by the 
mouth three times daily for two or three days before 
the operation, and afterward in 60-grain doses by the 
rectum three times daily for two or three days, or longer 
if necessary. 

As for instruments and sponges, there is needed, 
besides the ordinary laparotomy set, two or three good 
gall-stone scoops, — nothing more than this usually ; 
and gauze sponges of assorted sizes, — especially some 
very large pieces of gauze, resembling in size small bath 
towels. These are extremely useful for checking capil- 
lary hemorrhage. 

As for the position of the patient during operation, 
it has been found that some sort of pad or pillow 
beneath the back, in the lower dorsal region, greatly 
facilitates exposure of the deeper parts of the field. By 
its use the ducts seem to be thrown forward and the 
lower abdominal viscera apparently fall away. Various 
modifications of this pad or support have been devised, 



264 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

— the best that we have seen is that in use at the Mt. 
Sinai Hospital in New York. This consists of a short, 
enamelled, movable iron slab, set edgewise in and 
across the table, and caused by a ratchet to rise and 
fall, as needed, beneath the patient's back. 1 

The question of what incision to use in operations on 
the gall-bladder has been much debated ; but most sur- 
geons now enter the abdomen through a long incision, 
splitting the right rectus muscle, and we believe it is 
good practice, when enlarging this incision, to carry it 
up in the interval between the xiphoid cartilage and 
the right costal margin as high as possible. The upper 
surface of the liver will thus be exposed freely, and, as 
Robson points out, by lifting the lower border of the 
liver, in bulk, and rotating it (if needful first drawing 
the organ downward from under cover of the ribs), 
the whole of the gall-bladder and the cystic and 
common ducts are brought near to the surface. 

M. H. Richardson has felt for some years that the 
method of opening extensively the abdominal cavity 
involves risk of subsequent hernia, and in a valuable 
paper, read before the American Medical Association, 
in 1904, he urged the advantage of entering the abdo- 
men by a muscle-splitting operation after the manner 
of the " McBurney incision " for appendicitis. Just 
how valuable an advance in the surgery of the bile 

1 Lilienthal describes this device as follows : " The operation has 
been greatly simplified by the employment of an operating table with an 
enamelled iron piece about six inches wide, which may be raised or low- 
ered by means of a crank, so as to serve instead of a sand-bag or pad 
under the patient's back. This device permits one to hyperextend the 
patient to any desired degree of lordosis. The gain in accessibility is 
really most remarkable." 



SURGERY OF THE BILE PASSAGES 265 

passages Richardson's method may prove, is doubtful. 
The careful suturing of the present day and gall-bladder 
drainage through a separate stab wound have greatly 
reduced the chances of hernia. Another and an im- 
portant advantage of the long incision near the median 
line, together with the extensive exposure of the ducts, 
is that exploration of adjacent organs is thus rendered 
easy, and supplementary operations are facilitated. 

As for the question of method in cholecystostomy, 
we believe that the employment of the so-called Mixter 
tube, in common use at the Massachusetts General Hos- 
pital, has material advantages. The Mixter tube is 
a short glass cylinder merely, from three to six inches 
long, as desired ; from a quarter to a half inch in diame- 
ter, non-fenestrated, and with a flange at one end, — in 
other words, it is a glass drainage tube with a flange. 
As used for cholecystostomy, this tube, flange end down- 
ward, is inserted into the opening in the gall-bladder 
and is tied tightly in place with a silk or catgut liga- 
ture, about the gall-bladder and above the flange. One 
or two gauze wicks are wrapped about the tube to pre- 
vent possible leakage. The ends of the ligature are left 
long and carried outside the abdomen. The gall-blad- 
der is dropped into its normal position, the tube is car- 
ried outside, and to it is attached a long rubber drain 
with a collecting bottle. 

The advantage of the Mixter tube is that with it no 
suturing of gall-bladder to abdominal wall is required, 
with the result that by just so much the danger of a 
mucus fistula is diminished, — granted, of course, that 
the ducts be free from stones. At the end of five or six 
days the wicks are removed ; at the end of eight or ten 



266 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

days the ligature at the knot is cut away from the tube, 
by means of a sharp-pointed bistury, and the tube is 
withdrawn. A long, narrow tract completely shut off 
by adhesions remains. It shrinks rapidly and closes 
entirely after a few days. 

In the experience of the writers it is an advan- 
tage to establish this gall-bladder drainage through a 
separate stab wound, opening outside of the linea semi- 
lunaris. The long abdominal incision may then be 
closed, thus reducing danger of hernia to a minimum. 
In a considerable number of cases, so treated, we have 
seen no subsequent hernias. 

Cholecystectomy is well performed in uncomplicated 
cases after the method described by Lilienthal. That 
writer's description is so satisfactory that we take the 
liberty of quoting it at length: — 

" The gall-bladder, having been located, is drawn tow- 
ard the external wound. If the viscus is very tense or 
is supposed to contain infectious fluid, it is isolated by 
gauze packings, and aspiration is performed in order to 
empty it as completely as possible. When the walls 
seem very friable, it is even wise to incise and empty 
the viscus, closing the opening by ligature or clamp 
before proceeding with the extirpation. The gall-blad- 
der is usually quite a tough organ, and in the majority 
of cases it may be grasped with an ovarian ring-clamp 
applied near its fundus, which at the same time closes 
the aspiration puncture. 

" The patient is then placed in the proper position 
by raising the movable piece of the table for about six 
inches; gauze packings are laid over the neighboring 
viscera, and the parts are exposed with the help of blunt 



SURGERY OF THE BILE PASSAGES 267 

retractors. Traction upon the gall-bladder is continued, 
and an incision with scissors is made through its peri- 
toneal covering at the fundus, about half an inch from 
its junction with the liver. One blade of the scissors is 
worked between the serous and fibrous coats of the vis- 
cus, and an incision parallel to its long axis is made 
first on its anterior and then on its posterior aspect. 
Usually some tough fibrous tissue has to be divided in 
order to free the fundus from the edge of the liver; 
then the viscus is further freed with the finger, tak- 
ing care not to lacerate hepatic tissue. Hemorrhage is 
usually very slight and is easily controlled by packing. 
Near the cystic duct the connection between the gall- 
bladder and the liver again becomes more intimate, and 
it may be necessary to divide fibrous tissue with the 
scissors, controlling an occasional little spurter with 
artery clamps. During this entire procedure traction is 
made by means of the ovarian clamp. When the cystic 
duct is reached, it is caught with a clamp, the jaws of 
which are at a right angle with the handles. Now with 
a haemostatic needle a traction suture of silk or chromi- 
cized catgut is passed directly through the cystic duct 
about one-quarter or one-third of an inch beyond the 
clamp (i.e. between the clamp and the common duct). 
The ends of this suture are tied together, but the suture 
itself is left free, so that if desired it may be withdrawn 
after the operation. In order to be prepared for possi- 
ble accidents, I usually put in two of these sutures. 
The gall-bladder is now ablated between the clamp and 
the traction sutures, after protecting any visible viscera 
with gauze. An assistant now makes traction by means 
of the sutures, raising the cystic duct toward the ex- 



268 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

temal wound. If the cystic duct is patent, bile will 
probably flow and the cystic artery or arteries will 
spurt. If there is no bleeding, traction on the sutures 
should be released until the vessel spurts. It is then 
caught and ligated. This done, the rest of the opera- 
tion may proceed at leisure. 

" The cystic duct being now freed from its fibrous 
connection with the liver, traction upon the sutures will 
bring the common and hepatic ducts into view, and if 
the cystic is patent, a large probe may easily be passed 
under guidance of the eye in either direction. If the 
cystic is not patent, it is not wise to trust to palpa- 
tion in determining the presence or absence of calculi 
in the other ducts, but the cystic should be slit with 
scissors down even into the common duct, if necessary, 
or until there is a free flow of bile. In the absence of 
stones, a large-headed probe may now be passed into 
the duodenum. Large stones in the common duct may 
be removed through a prolongation of this slit, and 
stones from the hepatic may be brought to the opening 
by manipulation, or may even be removed through a 
separate incision into the hepatic duct." 

Speaking of cholecystectomy, W. J. Mayo, writing 
in 1903, 1 says when it is indicated for cases of stone 
impacted in the cystic duct : " The duct and cystic 
vessels are caught with curved forceps just beneath the 
impacted stone and tied. These sutures are then cut 
across and the gall-bladder and duct with the stone 
removed from below upward, almost by traction alone, 
with an occasional division of some more firm adhesion 
to the liver." And again : " Should the walls of the gall- 

1 Journal of American Medical Association, Dec. 26, 1903. 



SURGERY OF THE BILE PASSAGES 269 

bladder have undergone marked changes, or angulation 
and stricture of the cystic duct resulting in mucus 
fistula seem a possible outcome, cholecystectomy is 
more certain to afford permanent relief. If the cystic 
duct is completely obstructed so that the walls of the 
gall-bladder contain no bile, it is a simple operation to 
detach the organ from the liver and ligate with catgut 
at the base ; but if the gall-bladder participates in the 
biliary circulation, in spite of the obstruction, it is not 
always wise to ligate the cystic duct, especially if 
there is a cholangitis present." 1 Under such circum- 
stances, to facilitate drainage, Mayo has devised his 
well-known procedure of removing the fundus and enu- 
cleating the lining membrane of the gall-bladder, leaving 
the outer layer with the serosa as a shell or pouch into 
which the drainage tube may be fastened securely. 

Removal of the damaged gall-bladder and cystic 
duct carries out the second of our cardinal rules ; but 
when we come to the question of operation upon the 
other passages, — upon the hepatic and common ducts, 
— we find obviously that removal of damaged tissue is 
rarely possible, though removal of gall-stones is essential 
and inevitable. 

Up to a few years ago most surgeons felt that the 
operation of choledochotomy should be performed with 
the greatest caution and the least possible disturbance 
to structure. Even the crushing and needling of gall- 
stones in the ducts, without opening the lumen, was 
advised and practised. Halsted of Baltimore designed 
an ingenious little instrument, known as " Halsted's 
hammer," which could be slipped into the duct, when 

1 W. J. Mayo, in Boston Medical and Surgical Journal, May 21, 1903. 



270 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

that passage was open, and over it the duct could easily 
be sutured, as a seamstress darns a stocking-toe over a 
ball. In other words, the ducts, when opened at all, 
were opened fearfully and were reclosed immediately. 
We have now learned that suture of the ducts is not 
essential to their restoration of function. When slit up 
they heal as readily as does the urethra after the opera- 
tion of perineal urethrotomy. It is our custom nowa- 
days to open the ducts fearlessly when that is necessary 
for the removal of stones, and to drain them, usually 
without suture, when such drainage readily can be 
applied. 

It was an appreciation of the practicability of such 
drainage that led to the adoption of so-called hepatic 
drainage, — commonly associated with the name of 
Kehr, though Richardson employed it as long ago as 
1888, and other surgeons frequently have adopted the 
same measure. The object of hepatic drainage is to 
withdraw all bile at once to the surface, leaving dry 
the common duct so far as possible, and to encour- 
age the expulsion by drainage of stones possibly lodged 
in the hepatic duct or its radicals. 

Various duct-incisions for hepatic drainage have been 
employed ; but as long as the opening in the duct is 
large enough comfortably to admit the drainage tube, 
the results are almost uniformly satisfactory, no matter 
where the duct be opened. Kehr incises the common 
duct and pushes his tube up two inches into the hepatic 
duct. Other surgeons slit up the cystic and common 
ducts and through this large orifice insert a tube, which, 
in either case, should be lightly stitched in with catgut. 

This drainage of the ducts serves to carry off infec- 



SURGERY OF THE BILE PASSAGES 271 

tious material. That is its great object. Cholangitis, 
in varying grades, practically is always present, especially 
if there be stones in the ducts ; and drainage in such 
infected cases is as essential as is drainage for pleural 
empyema. 

Seeking for stones in the ducts is sometimes a diffi- 
cult matter ; but the improved technique of recent years 
has rendered finding them more certain than formerly. 
Straightening out the passages, as described by Lilienthal, 
is a great help. Kuhn * describes at length his method 
of injection, which he claims will always discover stones 
in the common ducts. He fastens a nozzle into the gall- 
bladder or cystic duct and forces water in by hydrostatic 
pressure. Provided the ducts are clear, the water will 
disappear, not immediately, but in a short time, thus 
showing that its flow is taking place into the bowel. 
If, however, water returns and keeps returning in spite 
of increased pressure, an obstruction is indicated. 
Kuhn's method has not been generally adopted, for the 
reason that palpation and probing usually will settle 
the question of obstruction and will determine the 
exact location of the stone. 

So long as stones are in the first portion of the com- 
mon duct, their detection and removal are not difficult, 
— be it borne in mind always that a considerable dilata- 
tion of the duct is commonly present in cases of chronic 
obstruction, so that often the passage may be explored 
with the finger. When the stone or stones are lodged 
in that portion of the duct behind the duodenum or in 
the ampulla, a more difficult problem is presented to 
the surgeon. Two well-recognized methods for exploring 
1 Franz Kuhn, Berlin, Therapeutische Monatshefte, April, 1903. 



272 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

this concealed region are in use, — the trans-duodenal 
route and the retro-duodenal route. McBurney, in 1891, 
was the first surgeon to employ the trans-duodenal route. 
His procedure consists in opening the duodenum from 
the front, finding the ampulla, and removing the stone 
through the duodenum itself. This method is effective 
and usually successful. It has the disadvantage of 
involving the interior of the gut in the field of opera- 
tion, and adding, consequently, to the risk of sepsis. 

C. M. Cooper, in a short letter published in the 
Annals of Surgery for September, 1903, gave what he 
believed to be an original method of reaching the post- 
duodenal portion of the duct by means of reflecting the 
duodenum and not opening it. In the same volume, 
however, 1 A. A. Berg had already described, with excel- 
lent plates, the same operation. This retro-duodenal 
method of Berg and Cooper consists in incising the 
peritoneum to the right of the duodenum, in reflect- 
ing that viscus, and so following down the common 
duct directly to its termination in the intestine. The 
writers believe that the latter method is to be preferred. 
After removing the stone it is well to suture the duct, 
leaving gauze drainage behind the duodenum. 

From what has been said, it must be apparent that 
the removal of all stones, when possible, is imperative. 
Stones in the gall-bladder and cystic duct may be 
reached readily and always. Stones in the hepatic duct 
may be encouraged to escape through long-continued 
and effective hepatic drainage. Stones in the common 
duct and ampulla may usually be removed at a primary 
operation, the patient's strength permitting. However, 

1 Annals of Surgery, August, 1903. 



SURGERY OF THE BILE PASSAGES 273 

sometimes, owing to the patient's weakness, or to ex- 
tensive adhesions, or to the presence of malignant 
disease, deep dissection of the common duct may be 
impossible. Efficient and permanent biliary drainage 
is demanded, however, even in such cases, and for this 
the operations of 

Cholecystenterostomy and Choledochenterostomy were de- 
vised. The nature of these operations has been explained 
already. The efficient and practicable method of doing 
them is by the use of the Murphy button, — the duo- 
denum or, in exceptional cases, the colon itself being 
drawn up and made to anastomose with the gall-bladder 
or with the common duct. 

Disease of the bile passages is frequently associated 
with pancreatic and with pyloric and duodenal disease, 
as has been stated already, and the nature of such 
association we describe in this book. Suffice it here to 
say that cases of chronic pancreatitis due to duct ob- 
struction often are treated successfully by drainage 
of the bile passages, while pyloric disease — ulceration 
and stenosis associated with adhesions to the gall- 
bladder and ducts — is remedied by the breaking up of 
adhesions and appropriate supplementary operations on 
the stomach, Finney's operation or gastro-enterostomy. 

Tumors of the bile passages are removable or are 
to be treated palliatively. As a rule those tumors only 
may be removed which involve the gall-bladder alone ; 
rarely has it been found possible to remove tumors, and 
especially malignant tumors, of the bile-ducts. As we 
have stated, permanent obstruction of the ducts may be 
relieved by cholecystenterostomy, — when the obstruc- 
tion is malignant, anastomosis between the gall-bladder 



274 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

and transverse colon is indicated ; in non-malignant 
diseases the anastomosis should be made, if possible, 
between the gall-bladder and the duodenum. 

Richardson, in an article already quoted, 1 urges the 
propriety of removing gall-stones whenever discovered 
in the course of abdominal operations undertaken for 
lesions other than those of the bile passages. We 
believe his argument to be cogent and final ; for, as we 
have frequently pointed out, gall-stones, even though 
quiescent, may at any time give rise to trouble ; and 
their removal through cholecystostomy, with a small 
stab wound and drainage, does not add materially to 
the risks of an abdominal section. 

From the foregoing paragraphs it must be apparent 
that we deem drainage of the deep field an essential in 
all operations on the bile passages. We have pointed 
out that an infection always is present, even when 
symptoms are quiescent ; infection demands drainage. 
We do not recognize as proper the manoeuvre sometimes 
undertaken, of removing by cholecystectomy an ap- 
parently innocuous gall-bladder full of stones, discovered 
in the course of some other operation, unless at the same 
time drainage be established. Such a cholecystectomy 
without drainage occasionally has been done, and the 
abdominal wound has been closed tightly without 
resulting damage ; but we regard this result as a 
piece of undeserved good fortune to the surgeon, for 
every operator of experience knows that a ligature on 
the cystic duct does not always hold, and that leakage 
sometimes occurs with a resulting general infection of 
the peritoneum. If the surgeon removes the gall-bladder, 
he must drain the stump. 

1 Journal of the American Medical Association, Sept. 3, 1904. 



SURGERY OF THE BILE PASSAGES 275 

We hope that enough has now been said to demonstrate 
without cavil the soundness of the three cardinal rules 
with which we began this chapter : — 

1. Remove stones ; for if left behind they are very- 
sure to cause subsequent disturbance, and we know, 
conversely, that after the thorough removal of stones 
their recurrence is almost unknown. 

2. Remove, so far as possible, all disorganized, de- 
generated, and permanently crippled tissue ; for we 
have seen how such tissue, when left behind, may 
become a nidus for subsequent inflammation, stone 
formation, and a return to the invalid condition. 

3. Drain ; for without drainage we have no certainty 
of the removal of infectious material. 



CHAPTER X 

THE PANCREAS 

To one reading the literature of diseases of the pan- 
creas the striking thought is that most of our knowledge 
of these diseases is accidental. What we know has 
come from the study of cases upon which the clinician 
and surgeon have happened, and they have been able to 
explain them only by the autopsies that have followed, 
or they have explained them partially from the findings 
at operation, — findings combined with hypotheses for- 
mulated later. All this is true of many of our advances 
in the realm of the known ; but it is perhaps more 
evident with pancreas disease than with any other 
subject in the domain of medicine. 

More careful autopsies and more carefully observed 
clinical analyses, since the way was pointed out by 
Fitz about fifteen years ago, have led to the knowledge 
that disease of the pancreas is more common than used 
to be thought. Still, it is acknowledged, even by those 
who pretend to great experience, that diseases of the 
pancreas are very difficult in the diagnosis. A reason 
is not far to seek. When all has been said and written, 
the pancreas is found rarely affected so as to appear the 
central, or causative, factor in the symptom-complex of 
an obscure case. And further, even when the pancreas 
does turn out to be the source of symptoms, these symp- 
toms are so often obscured by other symptoms which 

.276 



THE PANCREAS 211 

can be interpreted in terms of other organs, that a 
mistake or partial diagnosis is a usual result. 

The position of the pancreas, with its head beneath 
the pylorus and tucked into the bend of the duodenum, 
its duct uniting occasionally with the bile-duct within 
the substance of the gland just before their entry into 
the duodenum, its tail in close relation to the spleen 
and left kidney, its body overlying the great vessels, — 
this position tends to refer symptoms, truly arising from 
itself, to other more prominent organs. On the other 
hand, diseased conditions of other organs, especially of 
the bile passages, give rise, as has already been de- 
scribed, to morbid changes in the pancreas, and the 
symptoms resulting from these changes are wont to be 
regarded as part of the symptoms of the disease known 
to exist elsewhere. 

In spite of the relative infrequency of pancreas 
disease, the relief which has come from certain operative 
measures, taken largely by accident, makes it imperative 
that the clinician should appreciate the symptoms 
appearing in the course of disease of this organ. 

Diseases of the pancreas are, (1) hemorrhage into the 
pancreas, — acute pancreatitis, usually of a hemor- 
rhagic character and, if survived, frequently followed 
by abscess or gangrene ; (2) an infective process ad- 
vancing through the duct, due to the same causes as set 
up infection in the bile passages ; (3) a chronic inter- 
stitial pancreatitis, probably of two varieties, one involv- 
ing the lobules, and the other the acini of the gland, 
showing itself especially about the islands of Langer- 
hans, — these interstitial forms are due to long-standing 
local inflammatory conditions in the ducts, as well as 



278 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

to the general systemic conditions producing interstitial 
atrophy in other organs ; (4) neoplasms of the pancreas, 
of various kinds, cancer being by far the most common 
and important ; (5) tuberculosis ; (6) tertiary syphilis ; 
(7) calculi ; and finally, (8) cystic tumors in or about 
the organ, all of which go under the generic name of 
pancreatic cysts. 

So far the majority of these pancreas diseases have 
come under clinical observation during operations 
undertaken for other conditions, or during the course 
of exploratory laparotomies. As the diagnosis is so 
difficult, it is necessary for the surgeon to bear the 
pancreas in mind when he is doing his various investi- 
gating operations, else he may miss the cause of the 
trouble for which he is operating. 

One of the signs which should put the surgeon on the 
track of the pancreas is the presence of fat necrosis. 
On opening the abdomen the finding of disseminated 
nodules of fat necrosis should at once make the operator 
feel that there has been a definite lesion of the pancreas. 
The necrosed fat nodules may be differentiated from 
tubercles and cancer nodules, in that they are raised 
above the surface of the omentum and other fat-pro- 
ducing portions of the abdomen. The white or yellow 
opaque color is clearly marked off from the translucent 
yellow of normal fat. The fat necrosis is always most 
extensive in the neighborhood of the pancreas. The 
disseminated foci may appear within twenty-four to 
forty-eight hours after the onset of symptoms. 

Robson and Moynihan are inclined to doubt whether 
multiple fat necrosis is always associated with de- 
struction of pancreatic tissue ; nevertheless, the combi- 



THE PANCREAS 279 

nation of fat necrosis with pancreas disease is so 
frequent as to demand instant inspection of the pan- 
creas when the fat necrosis is present. 

(1) Hemorrhage into the pancreas, or pancreatic apo- 
plexy, is characterized by the sudden onset of pain, 
either diffused or localized between the xiphoid and the 
umbilicus, associated with collapse. The symptoms 
may suggest perforation of the stomach or duodenum 
from latent ulcer, for there may have been indefinite 
digestive disturbances for some time, to complete the 
mystification. 

So one may be tempted to do an immediate explora- 
tory operation, but if one leans at all toward the 
diagnosis of hemorrhage into the pancreas, it is well to 
wait. The condition usually is fatal, and to add an 
operation would surely turn the scale toward fatality ; 
moreover, the hemorrhage is practically never so 
extensive as to demand operative interference for its 
control. Small hemorrhages may be survived, as has 
been demonstrated at autopsy. Moderate hemorrhages 
may induce secondary changes. The hemorrhagic 
infarct may become infected and an abscess form, or 
extensive gangrenous sloughing may take place. These 
secondary conditions may lead to destruction of neigh- 
boring organs, or to death in a few days from septic 
absorption. Cases are on record in which the abscess 
discharged into the stomach or bowel, so that, if the 
observation was correct, nearly the whole of the ne- 
crotic pancreas was passed by rectum, yet recovery took 
place. Operations have succeeded for those secondary 
conditions, in which abscess or necrotic foci have been 
found and drained. Such operations are legitimate. 



280 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

When successful, they are among the most brilliant of 
surgical procedures. 

(2) Another form of acute pancreatitis is found usu- 
ally associated with the presence of gall-stones in the 
bile passages, and follows the inflammation set up by 
their passage through the common duct. Opie has 
advanced the interesting and ingenious hypothesis that 
violent pancreatic inflammation is due to the back- 
ward flowing of bile into the duct of Wirsung. This 
flow of bile into the pancreatic duct is brought about, 
he thinks, by the lodgement of a small stone in the 
ampulla of Vater, just behind the papilla of the common 
duct as it enters the duodenum. The stone must not be 
large enough to occlude the pancreatic duct, since a sim- 
ple damming back of the pancreatic secretion will not 
produce an acute inflammatory process. It is the pres- 
ence of bile that causes the disturbance. Opie supports 
this hypothesis by the results of animal experimen- 
tation. Surgeons, however, have found similar pan- 
creatic conditions when no gall-stones have been present, 
as well as when large gall-stones have been found in the 
common duct. On the whole, one may conclude that 
Opie's is but one of a number of methods of inducing 
violent inflammations in the pancreas, — inflammations 
leading to results similar in character to those produced 
by hemorrhages. 

The most important lesson, however, to be drawn 
from this variety of acute pancreatitis and its sequelae 
is a realization of the menace to health and even to life 
which gall-stones must always present. All the writers 
and collectors of cases agree that inflammatory disease 
of the pancreas is frequently associated with gall-stones. 



THE PANCREAS 281 

(3) Chronic interstitial pancreatitis, from the opera- 
tive point of view, presents a brilliant series of happy 
blunders. The cases have been diagnosticated after the 
event, but the favorable results are not yet fully under- 
stood. Indefinite symptoms pointing mainly to bile- 
duct disease have led to operative measures. Frequently 
no gall-stones have been discovered, but the head of the 
pancreas has been found enlarged and infiltrated, so as 
to constrict, or partially constrict, the common duct as 
it passes through the pancreas. Jaundice has been a 
frequent symptom, and the gall-bladder has been found 
enlarged at times and at times contracted. In emaciated 
subjects a tumor has been felt which has been found to 
be the head of the pancreas. The tumor, in a number 
of instances, has been regarded as malignant, and being 
left, only the recovery of the patient has led to a change 
in the diagnosis. The operation has consisted simply 
of draining the gall-bladder or occasionally doing an 
anastomosis between the gall-bladder and the duo- 
denum. Sometimes this anastomosis has been done at 
a secondary operation. The results, in a number of 
cases, have been brilliant ; the jaundice has cleared up, 
and after a number of days inflammation has subsided, 
so that in the case of cholecystostomy, bile has again 
appeared in the stools. Finally, the fistula has closed 
and recovery has persisted. 

In unfortunate cases, when death has occurred, exten- 
sive inflammatory exudate has been found in the pan- 
creas, with the formation of connective tissue. This 
form of chronic interstitial pancreatitis is of the inter- 
lobular variety, and is rarely associated with diabetes. . 

Just what takes place through drainage of the gall- 



282 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

bladder is hard to say, especially as in one case, reported 
by Robson and Moynihan, the gall-bladder was not 
drained, and absolutely nothing was done beyond the 
exploratory operation. Even in this case, within a 
couple of weeks, the jaundice had gone ; and at the end 
of three weeks this moribund patient went home, — 
the tumor had disappeared, and she was well once more. 
Certainly this case, taken in conjunction with those in 
which drainage has been instituted, makes it seem possi- 
ble that drainage alone may not deserve the credit for 
certain cures. 

(4) Malignant disease may occur either primarily or 
secondarily in the pancreas, and may cause obstruction 
of the ducts passing through the gland's substance. 
When found in the course of an exploratory laparotomy, 
a malignant tumor is best left alone. Employ only 
such proceedings as may relieve the patient, — drainage 
of the gall-bladder, or gastro-enterostomy if the lumen of 
the duodenum is in danger of being occluded. Cases 
supposed to be malignant have been proved to be in- 
flammatory through the recovery of the patient. 

(5) Tuberculosis and 

(6) Tertiary syphilis do not concern this discussion. 

(7) Pancreatic lithiasis is seen, but it is by no means 
as common as stone formation in the bile-ducts. Its 
diagnosis practically is impossible except from finding 
stones in the faeces. The pain of pancreatic lithiasis is 
described as colicky in character, and is said to be less 
severe than that of gall-stones ; but as all degrees of 
severity are present in biliary calculi, the distinction is 
not obvious. Tenderness, if present, is located over the 
pancreas. Diabetes is wont to be associated with 



THE PANCREAS 283 

pancreatic calculi rather than with biliary calculi, and 
in pancreatic lithiasis there may be a fatty diarrhoea. 
It is rare that we can group together before operation 
symptoms enough to make a clear diagnosis of pancre- 
atic calculi. For the most part, reporters of cases men- 
tion the presence of multiple calculi, and even a diffuse 
paste or calcareous scales, as well as well-developed 
stones, throughout the length of the duct of Wirsung. 
The outlook for cure by operation, even with a posi- 
tive diagnosis of calculi, is not very encouraging. 

(8) The form of pancreatic disease which most legiti- 
mately belongs to the domain of surgery is the pan- 
creatic cyst. Under the term " cyst" are grouped several 
different pathological processes. Frequently, in fact, 
the so-called pancreatic cyst is entirely outside of the 
body of the pancreas. 

The form of pancreatic cyst typical in its develop- 
ment, and most easy of diagnosis, may be seen as a 
tumor, which has appeared after a blow in the pit of 
the stomach, or after an accident in which the patient 
has been caught and crushed between two solid objects, 
— the greater part of the pressure coming across the 
upper part of his abdomen. This accident, should it 
result in injury to the pancreas, is often followed by the 
development of a tumor in a few hours or after several 
days. Such a tumor is located usually in the median 
line above the umbilicus. For the most part it develops 
rapidly and becomes tense and fluctuant. Such a tumor, 
a pseudo-cyst of the pancreas, is due to the extravasa- 
tion of blood and secretion about the pancreas itself, or 
to sealing of the foramen of Winslow with inflammatory 
exudate, and the development of a cyst within the lesser 



284 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

cavity of the omentum. Wherever the cyst be, the 
crushed pancreas is liable to furnish to it a certain 
amount of pancreatic fluid, as can be demonstrated by 
appropriate tests. Hence the name " pancreatic cyst " is 
applied to these extra-glandular tumors. 

Besides these traumatic cysts, pure retention cysts 
are found in the gland. They are usually small and 
slow in development, and may not give rise to symp- 
toms. In a few reported instances they have become 
large enough to be mistaken for immense ovarian 
tumors, so completely have they filled the abdomen. 
At times their origin is shrouded in mystery, even on 
the autopsy table. Pancreatic calculi, cicatrices, press- 
ure from without, are causes of such cyst formations. 

Proliferation cysts are adenomatous or epithelioma- 
tous. Hydatid cysts rarely may be found in the 
pancreas as well as in the other abdominal organs. 
Finally, in children, there may be congenital cysts of 
the pancreas, as there may be cystic disease of the 
kidneys. 

Such are the diseases which occur in the pancreas. 
Their enumeration emphasizes the statement made in 
the early part of this chapter, that, owing to the posi- 
tion of the pancreas, other organs are wont to be 
involved with it, and to furnish the more prominent 
symptoms, even when the disease is primary in the pan- 
creas. Further, it must be repeated that pathological 
conditions arising in other organs often obscure second- 
ary, but important, changes in the pancreas. 

What are the symptoms associated with extensive 
disease of the pancreas ? The list is a slight modifica- 
tion of that presented in great detail by Robson in his 



THE PANCREAS 285 

Hunterian Lectures. Under disorders of digestion are 
to be considered : — 

(V) Steatorrhea, or fatty stools ; and one should 
remember that the fat may be free, or appear as fat- or 
soap-crystals. The latter may appear also in jaundice 
unassociated with pancreatic disease. 

(F) Azotorrhcea, due to imperfect digestion of proteid 
material, particularly of meat. This is a condition that 
has to be sought for ; it does not force itself upon one. 
Soft, bulky stools containing both fat and undigested 
muscle fibres are very suggestive of a pancreatic com- 
plication. 

(V) Siatorrhcea, or excessive pancreatic secretion, is a 
symptom mentioned by Senn ; but it is of no practical 
importance. 

(d) Diarrhoea, — this is not a watery affair, but 
characterized by frequent, large, soft, greasy stools. 

(V) Dyspeptic symptoms with anorexia; the patient 
has a great distaste for food, especially the fatty foods, 
and he has more or less discomfort, heaviness after 
eating, as well as heartburn ; sometimes he has nausea 
and vomiting, both of which are apt to be present in 
the more acute attacks. 

The physical signs are : — 

(V) Great emaciation, as the result of interference 
with nutrition. 

(5) A tumor ; and Robson has found this much more 
frequently than the text-books have stated it to be. 

(c) Fever, which is not a prominent sign ; in the cases 
of malignant disease a subnormal temperature is not 
unusual. 

(d) Tenderness, and accompanying muscular spasm 



286 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

— variable. At times the location of the pain is defi- 
nite ; at other times, even with extensive lesions, there 
is no pain or tenderness ; the pain may be diffuse. 

(V) Evidence of pressure is manifested by the condi- 
tion of other organs. Of special note is the presence of 
ascites from pressure on the portal vein ; and jaundice, 
which is to be expected from the involvement of the 
common duct in the head of the pancreas. 

(/) Hemorrhage, when it exists, is not shown by 
blood in the stools. We may observe the general symp- 
toms of internal hemorrhage. It is not to be forgotten 
that a hemorrhagic diathesis, so to speak, may be devel- 
oped in those suffering from pancreatic disease. The 
administration of calcic chloride as a means of avert- 
ing hemorrhage is recommended before any operation 
upon the pancreas. 

Metabolic changes are shown by the presence of (&) 
glycosuria, — this symptom is too inconstant for diag- 
nostic purposes (when it appears, while the patient is 
under observation, it is an unfavorable sign, coming as 
it does when the destruction of pancreatic tissue is very 
far advanced ; hence, its appearance is practically a 
contraindication for operation) ; (&) the " pancreatic re- 
action " in the urine. Robson believes this the great 
enlightener in making the diagnosis of pancreatic dis- 
ease. We shall describe it at length later on. 

Special tests : — 

1. The production of alimentary glycosuria — de- 
monstrating the insufficiency of pancreatic juice to take 
care of an excess of ingested sugar. To ascertain this, 
two or three ounces of sugar are given to the patient 
before breakfast. The early morning urine is saved and 



THE PANCREAS 287 

tested as a control, and then the urine is tested for sugar 
every two hours after breakfast. Sugar usually will be 
found, if at all, in the first specimen of urine. 

2. Sahli's test : When a gelatine capsule, hardened in 
formalin and filled with iodoform or salol, is adminis- 
tered, it will pass the stomach without being dissolved, 
but will be dissolved in the pancreatic juice if that is 
present ; thus, in from four to eight hours an examina- 
tion of the urine will show the presence of the drug, if 
pancreatic juice is being secreted. In the absence of 
pancreatic juice, the drug will not appear in the urine. 

3. Pcmcreatic Reaction. — Mr. Mayo Robson has stated 
that he has received great assistance in the recognition 
of inflammatory diseases of the pancreas by the use of 
the examination of the urine according to the tests de- 
vised by P. J. Cammidge. In spite of a number of 
sharp criticisms by certain English writers (made, often, 
in a churlish spirit) Mr. Robson in 1906 reiterated 
his belief in the value of these tests as an aid to 
diagnosis. Cammidge first described his test in the 
Arris and Gale Lecture for 190-1. In order, however, 
to meet objections raised to his work, he modified his 
technique, and in 1906 published a new, or rather revised, 
method. This he supplemented with the result obtained 
by the examination of one hundred specimens of urine 
from ninety-four persons. In chronic pancreatitis he 
presents twenty-eight examinations with positive results 
in all. Of cancer of the pancreas he had five cases, with 
one positive examination. Of stone in the bile passages, 
but without pancreatitis, he had nine cases, all of which 
were negative as to the production of the sugar crystals. 

Six of the first groups were reexamined after they 



288 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

had been operated upon by Mr. Robson for the relief of 
the condition. In none of them was the test found to 
be positive. The control cases that were examined 
numbered fifty-two, and included cases of cancer of the 
stomach or liver, cirrhosis of the liver, hepatic abscess, 
duodenal ulcer, appendicitis, tuberculosis of the intes- 
tines, and many other forms of disease, and finally the 
examination of twenty-two presumably normal persons. 

In contradistinction to this, there have come under our 
notice two cases in which apparently a positive reaction 
was obtained when the pancreas was found intact at the 
autopsy. One of these was done according to the tech- 
nique first described by Cammidge, and the second 
according to the later method. The former case was 
one of cancer of the stomach with extension to the 
oesophagus and duodenum and secondary deposits in the 
retroperitoneal and bronchial lymph nodes and in 
the lung. The second was diagnosticed as an acute sup- 
purative pancreatitis, and was so considered, even after 
operation. This idea was confirmed by finding many 
typical crystals, as described by Cammidge, in the urine, 
but the autopsy showed that the process was located 
wholly in the liver and that the pancreas was free in 
every respect. Other cases have reacted properly to the 
test. Cammidge's method as given in 1906 is as 
follows : — 

" A specimen of the twenty-four hours' urine, or of 
the mixed morning and evening secretions, is filtered 
several times through the same filter-paper and examined 
for albumen, sugar, bile, urobilin, and indican. A quan- 
titative estimation of the chlorides, phosphates, and urea 
is also made and the centrifugalized deposit from the 
urine examined microscopically for calcium oxalate 



288a SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

crystals. If the urine is found to be free from sugar 
and albumen, and is acid in reaction, 1 c.c. of strong 
hydrochloric acid (sp. gr. 1.16) is mixed with 20 c.c. of 
the clear filtrate and the mixture gently boiled on the 
sand-bath in a small flask, having a long-stemmed funnel 
in the neck to act as a condenser. After ten minutes' 
boiling the flask is well cooled in a stream of water and 
the contents made up to 20 c.c. with cold distilled water. 
The excess of acid present is neutralized by slowly 
adding 4 g. of lead carbonate. After standing for a 
few minutes to allow of the completion of the reaction, 
the flask is again cooled in running water and the con- 
tents filtered. A perfectly clear filtrate is secured. The 
filtrate is then well shaken with 4 gr. of powdered tri- 
basic lead acetate and the resulting precipitate removed 
by filtration. To remove the lead the clear filtrate is 
well shaken with 2 g. of finely powdered sodium sul- 
phate, the mixture heated to the boiling-point, then 
cooled to as low a temperature as possible in a stream 
of cold water, and the white precipitate removed by 
careful filtration ; 10 c.c. of the perfectly clear trans- 
parent filtrate is made up to 18 c.c. with distilled water 
and added to .8 g. of phenylhydrazin hydrochlorate, 
2 g. of powdered sodium acetate, and 1 c.c. of 50 per 
cent acetic acid contained in a small flask fitted with 
a funnel condenser. The mixture is boiled on a sand- 
bath for ten minutes and then filtered hot through a 
filter-paper moistened with hot water into a test-tube 
provided with a 15 c.c. mark. Should the filtrate fail 
to reach the mark, it is made up to 15 c.c. with hot 
distilled water, but in my own work I find this is rarely 
necessary, as after a little practice it is possible to 
regulate the boiling process so that the final result 
always comes out at between 15 and 16 c.c. In well- 
marked cases of pancreatic inflammation a light yellow 
flocculent precipitate should form in a few hours, but it 



THE PANCREAS 289 

may be necessary to leave the preparation to stand over 
night before a deposit occurs. Under the microscope 
the precipitate is seen to consist of long, light-yellow, 
flexible, hair-like crystals, arranged in sheaves which, 
when irrigated with 33 per cent sulphuric acid, melt 
away and disappear in ten to fifteen seconds after the 
acid first touches them." 

Cammidge makes no absolute claims for the inerrancy 
of his method, but thinks that the evidence available 
suggests that it may be of considerable assistance in 
diagnosis of inflammatory processes in the pancreas. 

Anything which will aid in making a diagnosis of 
inflammatory conditions of the pancreas is of the 
greatest help at the present time. Certain cases 
demand operation at all hazards, but there is a class of 
cases where the differentiation between chronic pan- 
creatitis and cancer is of importance to the patient, and 
every offered aid should be carefully investigated and 
tried. It is only in this manner that the final value 
of the tests can be determined. 

Treatment. — The pancreas, the liver and ducts, and 
the stomach hang like three apples on a single stem, — 
the duodenum. Whatever affects one often affects the 
others. All are organs of digestion, but of them all the 
pancreas physiologically is by far the most important 
for purposes of digestion. One can live without a stom- 
ach, one can even live without the bile of the liver, but 
we have reason to believe that one cannot live long 
without the pancreas. So it is by a shrewd provision 
of nature that the pancreas is so placed and guarded as 
infrequently to be the subject of disease or injury. And 
it is a delicate organ, structurally, — easily damaged by 



290 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

violence, whenever violence may reach it ; gravely in- 
fected when infective agents penetrate its depths ; 
and when diseased, a potent menace to health and to 
life. 

So we have seen, in this brief study of its derange- 
ments, that traumatism is the commonest cause of its 
cysts ; that mechanical irritation, through cholelithiasis, 
is the important cause of its chronic inflammations ; and 
that chemically irritating bile or infecting organisms 
from a diseased stomach or intestine are the causes of 
its acute diseases. 

Bearing etiology in mind, then, let us make some 
study of treatment ; and we know from our study of 
the pathology that all active treatment of these troubles 
must be surgical. Sometimes the Carlsbad regimen, pre- 
scribed for disease of the bile passages, may chance to 
relieve an unexpected pancreatic complication ; but this 
is hypothesis. 

Broadly speaking, there are three types of pancreatic 
disease for which we operate : — 

Cysts, in which the results of operation are good. 

Acute inflammations, in which the results are bad. 

Chronic inflammations, in which the results are good. 

There are also tumors and adhesions, but as yet sur- 
gery concerns itself little with them. 

Cysts of the pancreas are either intra-glandular or 
extra-glandular. The former are small affairs usually,, 
but they may grow large, as has been said, and clini- 
cally they cannot be distinguished from the extra- 
glandular cysts. The symptoms of the two are similar, 
— gradually increasing pain, after considerable size has 
been reached, then vomiting, malnutrition, rapid wasting. 



THE PANCREAS 291 

One cannot make the diagnosis until he can feel the 
tumor. Often the mass protrudes between the stomach 
and colon. One notes the two areas of visceral tym- 
pany, with the tumor dulness between them. Rarely 
the cyst may bulge elsewhere. 

There are two methods of operating (for we discard 
absolutely the old aspiration), drainage and enucleation. 

Drainage is a very simple matter, and cures the 
patient. Open through the rectus muscle, tear through 
the mesocolon, draw up the cyst, and stitch it to the 
abdominal wound. The cyst may be opened at once, — 
the commonly practised method ; or one may wait three 
days for adhesions to form, and then open it. In either 
case, employ tube drainage. Before bringing the cyst 
forward, if its wall is tense, it may be well to relieve 
the internal pressure by aspiration. If the permanent 
opening is made at once, use care, by gauze packing, to 
prevent soiling and irritation of the peritoneum. 

When drainage has been established, cover the neigh- 
boring skin with zinc ointment to protect it from the 
acrid discharges. Employ a voluminous dressing. 

The cure is not prompt in these drainage operations. 
A fistula will persist for months or even a year or more, 
but eventually it will close. 

In ten days the patient may be sitting up, and may 
be out in the third week. 

These operations for cysts, therefore, are safe and 
easy. Bockel's figures, published in 1901, are as good 
as ever. Out of ninety-nine persons operated upon by 
immediate opening and drainage, ninety-two recovered, 
— a mortality of 7 per cent. Of sixteen operated upon 
in two sittings, all recovered. 



292 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Enucleation or extirpation of the cyst is an ideal 
operation, if it can be done, for the wound closes 
promptly and convalescence is short ; but enucleation 
is possible in exceptional cases only. Usually enuclea- 
tion is a bloody and difficult procedure. If there are 
extensive adhesions and a broad pedicle, the surgeon had 
best not attempt it. If there are but slight adhesions 
and the pedicle is narrow, the operation is feasible ; but 
such conditions are rare. Twenty-five cases of enuclea- 
tion are recorded, with four deaths. In any case drain- 
age must be employed to provide for hemorrhage. 

Cases of pancreatic cyst come properly into the cate- 
gory of digestive disorders, for in the end they do cause 
digestive symptoms of a marked type, and their removal 
effects brilliant cures. 

Acute inflammations of the pancreas present us with 
a different problem, — a discouraging problem. The 
condition is lethal, the outlook bad, no matter what we 
do. We have already dealt with the question of oper- 
ating immediately in the case of pancreatic apoplexy. 
In such case, with the patient in profound shock, we 
cannot advise immediate operation. We must wait. 
Sometimes the symptoms may subside, sometimes an 
acute inflammatory process may have begun, which, if 
left alone, may run on into a subacute form. 

We are not in accord with those who recommend 
long delay. If, after the immediate shock, the infec- 
tion is not subsiding, we believe in drainage to evacuate 
septic material. The operation then adds little to the 
already urgent risk. 

A small anterior incision, under local anaesthesia, if 
thought best, at once will settle the question of a spread- 



THE PANCREAS 293 

ing infection. If such an infection is present, drainage 
may be instituted. 

On the other hand, if we find that the general 
cavity of the peritoneum is not involved, posterior 
exploration and drainage may be employed. This is 
done by opening the back through a large incision at 
the left costovertebral angle. The operation is not 
difficult. The pancreas thus may be explored and 
drained extra-peritoneally. 

It is hard to see how one is to differentiate clinically 
such conditions from an acute pancreatitis due to septic 
invasions from without the organ. 

Fitz says, " Acute pancreatitis is to be suspected 
when a previously healthy person or sufferer from occa- 
sional attacks of indigestion is suddenly seized with 
violent pain in the epigastrium, followed by vomiting 
and collapse, and in the course of twenty-four hours 
by a circumscribed epigastric swelling, tympanitic or 
resistant, with slight rise of temperature." That might 
apply to acute pancreatic disease, however induced. If, 
now, the acute process in the pancreas be inaugurated 
by the sudden inrush of septic material from without, 
the course of the disease is not so overwhelmingly bad 
as in the cases of pancreatic apoplexy. If the apoplexy 
is to kill, it does so in a few hours. The acute septic 
invasions take days rather than hours. 

Whatever be the cause of these acute infections, sur- 
geons have to deal immediately with a grave disaster, 
in which the peritoneum is involved. So one must 
open from the front and drain. Indeed, the procedure 
is precisely that described four paragraphs back. If 
there be established a widespread peritonitis, both renal 



294 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

regions should be drained with tubes, as well as the 
pelvis. Gauze does not drain. In other words, one 
must treat the peritonitis as though its origin were in 
a perforated appendix or duodenum. 

The attendant should not immediately afterward 
start up the bowels with cathartics. Cleansing enem- 
ata, nutrient enemata, normal saline solution by 
rectum, in the veins, or under the skin, strychnine, 
gastric lavage, nothing whatever by the mouth for 
forty-eight hours, — such must be the after-treatment. 

If the acute case is not attacked at once, but is 
allowed to run into a subacute condition (indefinite 
term), extensive damage to the pancreas and to the 
surrounding tissue may result, with death as the finale. 
The pancreas will show suppuration and gangrene at 
the post mortem. 

Even if the patient be saved by operation, and if 
some degree of health be restored, there is always the 
underlying cause of the acute attack to be considered. 
That underlying cause may be disease of the stomach, 
the duodenum, or the bile passages, — all of which 
must be investigated by the diagnostician ; and if there 
be disease of these organs, it must be treated if one 
would avoid chronic invalidism. When all is said> the 
operation in acute pancreatitis is followed by a high 
mortality. We find thirty-two cases operated upon, 
with seventeen deaths. From the nature of the disease 
we cannot look for a death-rate much below 50 per 
cent. 

Chronic pancreatitis, especially the interlobular vari- 
ety, is by far the most interesting form of pancreatic 
disease just now presented to the surgeon. We have 



THE PANCREAS 295 

already referred to the mysterious cures with which the 
surgery of this disease is credited. The disease is often 
a digestive disorder of the first magnitude, in the sense 
that it is associated with faulty digestion, poor metabo- 
lism, pain, wasting. One will see it associated also with 
jaundice, and often one will find it impossible to dis- 
tinguish from disease of the bile passages. The reason 
for that confusion is obvious and inevitable: chronic 
pancreatitis frequently is associated with and dependent 
upon disease of the bile passages. Duodenal ulcer is 
another not uncommon cause or complication of 
pancreatitis. 

As we know, chronic pancreatitis may be due to 
partial or complete obstruction of the duct of Wirsung. 
A calculus in the lower portion of the common bile-duct, 
when that duct lies against the duct of Wirsung, may 
press upon the latter and cause obstruction and a back- 
ing up of the pancreatic secretions. Or the ampulla of 
Vater may be completely filled by a calculus, which 
thus dams back both bile and pancreatic juice. In 
either case there ensues a chronic pancreatitis associated 
with the biliary symptoms we have described. 

Wherever the stones, therefore, an operation for the 
removal of gall-stones, if at the same time we drain the 
passages, will often cure the pancreatitis. Often, too, 
even when the stone is overlooked, drainage of the bile 
passages will relieve pressure and congestion, relax the 
lumina of the ducts, and by allowing the calculus to 
escape either up or down, bring about a return to the 
normal. This is, therefore, an excellent reason, if no 
other reason existed, for providing drainage in every 
case of diseased bile passages associated with jaundice. 



296 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

There is that other class of cases of chronic pan- 
creatitis, however, already mentioned, — a mysterious 
class, in which the bile passages are free. Even in such 
cases operation with drainage has cured at times. It 
seems probable that in certain of these cases there is 
present a mild grade of infection, — in the duodenum, 
perhaps associated with ulcer, in the bile passages, and 
in the duct of Wirsung. The ampulla may be more or 
less occluded by inflammatory swelling. In such con- 
ditions cholecystostomy is indicated obviously, and the 
drainage thus established should be expected to pro- 
mote the reparative process. 

That case of Robson and Moynihan in which a simple 
exploration without drainage was followed by a cure 
cannot be explained on any such grounds. Indeed, we 
cannot believe that the operation had any bearing on the 
result. It is reasonable to suppose, however, that in 
some way a relief of obstruction took place coinci- 
dently with the operation, enabling the writers to 
chronicle a happy result. 

Of course, there are many cases which biliary drain- 
age does not cure. In the presence of advanced inter- 
stitial changes, with contraction or obliteration of ducts, 
drainage will not avail ; but one cannot be sure of the 
conditions until he has tried drainage. Our rule in 
these chronic cases, therefore, must be to establish 
drainage by cholecystostomy. Three or four weeks 
later, if it has become evident that the pancreatitis will 
not thus be relieved, the surgeon may decide to let the 
patient go on with a permanent biliary fistula, or he 
may do a secondary cholecystenterostomy. We know the 
mortality from the latter operation to be high. Rarely, 



THE PANCREAS 297 

in consequence of an enormously distended gall-bladder 
overlying the stomach, a cholecystogastrostomy has been 
done, and without ill effects from the bile outpoured 
into the stomach. 

As for tumors of the pancreas and calculi of the duct, 
much of what we have already written will apply to 
them. If the tumor, usually situated in the head of 
the organ, is malignant, nothing beyond drainage for 
palliation can be done. But often one cannot distin- 
guish a cancer from pancreatitis. If drainage be insti- 
tuted, the tumor may disappear, thus establishing the 
diagnosis of non-malignant disease. 

As for calculi, one cannot always recognize them, 
even at operation. They are rare. Sometimes they 
are discharged by the bowel. Sometimes biliary drain- 
age frees them and allows of their exit. At all events, 
when present, they form an integral part of the 
inflammatory process. 

Such, in outline, is the surgical problem of chronic 
pancreatitis ; and the experience of the last few years 
justifies us in feeling that in a considerable number 
of obscure obstinate " dyspepsias,'' resisting treatment, 
when the source of the trouble is to be sought some- 
where in the upper region of the abdomen, then the 
pancreas, alone or with its associated organs, often will 
be found at fault. 



CHAPTER XI 

ABDOMINAL PTOSIS 

Abdominal ptosis is a subject of great importance. 
We shall not attempt a discussion of all its phases, but 
briefly we shall point out what clinicians may do to 
relieve the symptoms and the condition ptosis of itself. 
Incidentally, too, we must say a word on the general 
subject of the etiology of ptosis, as there is a good deal 
of misunderstanding of that matter, so various are 
the views of sundry writers. 

Virchow long ago recognized visceral ptosis ; and 
movable kidneys have been observed for many years. In 
1881 Landau wrote a monograph calling attention to the 
importance of the movable kidney in women. Glenard, 
however, in 1885, was the first to show clearly and dis- 
tinctly that by ptosis of the abdominal organs one may 
explain on anatomical grounds a group of clinical symp- 
toms hitherto regarded as purely functional. Glenard 
maintained that sufferers from these functional dis- 
orders were cured of their dyspepsias and backaches and 
neurasthenias through relief to the ptoses found in their 
cases. He gave the name "enteroptosis" to the most 
common assemblage of derangements which he was 
accustomed to find ; namely, to ptosis of the intestines 
and stomach combined with a prolapsed right kidney. 
This combination of lesions has been called Glenard's 
disease. The term " splanchnoptosis " is applied to pro- 

298 



ABDOMINAL PTOSIS 299 

lapse of all the abdominal viscera, — a very rare condi- 
tion. Some German writers and others recently have 
used the term "splanchnoptosis" in place of the older and 
more common term. The displacement of single organs 
is designated by special words, "gastroptosis," "nephrop- 
tosis," " hepatoptosis," " splenoptosis," etc. Properly the 
term " enteroptosis" should be employed to describe pro- 
lapse of the intestines alone, but we shall follow the 
common usage as established by Glenard. 

Briefly, ptosis of the abdominal organs is due to a 
relaxation of their supports, so that they sag from their 
places. The consequent dragging upon vessels and nerves 
brings about certain changes in the circulation and in- 
nervation of organs, especially of those organs in the 
female pelvis. So the uterus may be forced out of 
place, and further distressing symptoms may result. 
Moreover, ptosis of the intestines removes an important 
support from beneath the upper abdominal organs. 

To distinguish cause and effect is difficult often, so 
closely are the various organs bound up together and 
dependent upon one another ; and the clinician, accord- 
ing to his bias, is wont to regard a patient as a gastric, 
gynecological, intestinal, or nervous case. 

The underlying causes of ptosis are still in dispute, so 
diversified are the conditions found and so great the 
range of symptoms accompanying them. In explana- 
tion of ptosis, Glenard suggested weakness of the abdom- 
inal muscles and a loss of intra-abdominal pressure or 
tone, which permits the stomach, intestines, and kidneys 
to sag. Some writers go further and suggest that the 
displacements are congenital ; while others put the 
blame upon improper clothes, especially on corsets and 



300 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

the bands of heavy skirts ; writers point out, also, the 
disturbing effects of pregnancy. After considering these 
statements and studying many patients, we cannot but 
believe that all such explanations are plausible, but that 
rarely does any single explanation suffice. 

The argument for a congenital origin of abdominal 
ptosis rests on the fact that the kidney in the embryo 
has a position similar to that of a displaced kidney in 
the adult. Late in embryonic life the kidney moves 
upward and disappears behind the ribs. The retention 
of the kidney in its early embryologic position is used 
to explain the displacements of the kidneys not unfre- 
quently found in children and also in young women who 
have not worn constricting clothing or been pregnant. 

Further, to advance the argument for congenital 
ptosis, it is generally acknowledged that persons with 
symptoms of nervous dyspepsia, with constipation and 
indefinite pains, conform to the type described by Gle- 
nard. These patients are thin, flat-chested, and long in 
the flank ; their back muscles are weak and their shoul- 
ders are drawn far back, while their heads slouch and 
their abdomens protrude. Of this type are practically 
all the men with movable kidneys. Women of this 
type add to their deformity often by wearing badly 
made corsets and heavy skirts. Persons, too, who stand 
for long hours at their work, shop girls behind counters 
and motormen on electric cars, are wont by their occu- 
pation to aggravate an already vicious tendency. Most 
women among us wear their clothes without regard to 
hygienic considerations. They hang heavy skirts by 
narrow bands from their waists, so that a drag is 
brought upon the intestines which lie in the lower part 



ABDOMINAL PTOSIS 301 

of the abdomen. The crowded intestines, in turn, press 
upon the pelvic organs beneath them. Corsets tend to 
accentuate the waist line ; they crowd down what is be- 
low and push up what is above. Straight-front corsets 
do not push the abdominal contents downward as do 
the old-fashioned corsets, though even straight corsets 
may produce other unpleasant changes in the anatomy. 
Often and fortunately, however, straight-front corsets 
when properly applied may suffice to correct enterop- 
tosis. In the course of physical examination of elderly 
women, it is not uncommon to find a permanent fur- 
row made in the costal margin due to corset pressure. 
In view of these facts one cannot but conclude that 
bands, heavy skirts, and corsets must be etiological fac- 
tors in ptosis. Finally, one encounters cases in women 
whose symptoms all date from a childbirth. Of such 
persons it is probable that many of the displacements 
were present previously, but did not become troublesome 
until after the labor. The onset of such symptoms may 
date from the birth of a first child, or may be due to a 
precipitate or difficult and instrumental delivery. In 
view of these facts we conclude, as has been said 
already, that there are many and various causes of abdom- 
inal ptosis. One could mention other causes, — trauma, 
falls, strains in lifting and reaching, over-exertion as 
from prolonged bicycle riding and even the persistent 
vomiting of seasickness ; and so on for many paragraphs. 
So many are the possibilities in our list that the wonder 
is how any woman escapes having some of the physical 
signs of ptosis of the abdominal and pelvic organs ; in- 
deed and as a fact, a large number of women do furnish 
such signs. 



302 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Movable kidneys, pulsating aortas, protuberant bellies, 
uterine displacements, and prolapses are phenomena seen 
daily in our clinics. Truly it is usual to find some of 
the signs which are dependent on ptosis of the abdom- 
inal or pelvic organs, when making the examination of 
any mature woman. 

It is striking, however, that in spite of this frequency 
of anatomical displacements, symptoms of ptosis are 
relatively rare. 

Glenard errs, for no man who has served in a clinic 
for women would be willing to agree with him, when 
he implies that all palpable kidneys are pathological 
and cause symptoms. And yet most of us will admit 
that every displaced organ has the potentiality for 
causing symptoms that may demand prompt surgical 
treatment for their relief. 

The misconceptions as to the frequency and serious- 
ness of ptosis arise commonly from the fact that some 
physicians and most surgeons see the rare and severe 
cases only, while other physicians see for the most part 
the many painless cases. 

What, then, is the process in the development of 
ptosis ? One cannot say definitely that in this or in 
that begins the vicious circle causing prolapse of the 
abdominal organs, yet in general terms one may use 
some such description as the following : — 

Owing to structural peculiarities, to flabby abdominal 
muscles weakened by severe illness, to improper cloth- 
ing, or to pregnancies, the normal abdominal tension is 
diminished ; the transverse colon is loosened, usually at 
the hepatic flexure, and sags downward ; it crowds the 
coils of the small intestine so that they in turn press 



ABDOMINAL PTOSIS 303 

upon the pelvic organs. With the loss of abdominal 
tone the whole colon then tends to collapse, and this 
collapse extends even to the rectum, so that there is 
no longer a dilated rectal ampulla behind and below 
the uterus. The muscles of the pelvic floor lose their 
resisting power, the uterus settles, and the coils of the 
small intestine are crowded still farther into the pelvis. 
There ensue modifications in the shape and position of 
the pelvic organs, and one finds a prolapsed, retroverted, 
and retrocessed uterus, and the various combinations 
familiar to gynecologists. The reader must not sup- 
pose that such superimposed pressure is the only cause 
of uterine displacements, but certainly it is a frequent 
cause. 

The stomach follows the intestines, for it no longer 
receives their normal support. As the stomach sinks, 
the aorta is left uncovered for several inches above its 
point of division. It may be palpated and may even 
be seen to pulsate. Indeed, this pulsation is often dis- 
agreeable and annoying to the patient. 

Note, now, that there is one complicating cause of 
intestinal prolapse, a cause which may be remedied by 
operation ; we refer to a separation of the recti muscles 
consequent to pregnancy. In such case the patient 
frequently has the sensation that her intestines are fall- 
ing out. Every motion causes abdominal straining and 
is frequently accompanied by a protrusion of the bowel 
between the muscles. The condition is that of a large 
ventral hernia. Cure the hernia by operation, and you 
will thus relieve greatly the ptosis. 

Other operations have been practised for intestinal 
ptosis. Lambotte has attached the splenic and hepatic 



304 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

flexures to the abdominal wall and thus restored the 
colon to its normal position, approximately. In his cases 
there had not been any great prolapse of the stomach ; 
he operated to relieve severe and repeated attacks of 
intestinal colic. He was successful. 

Sometimes the sigmoid flexure becomes dilated with 
retained faeces as a result of intestinal prolapse. The 
gut may expand greatly and in the course of time may 
develop a tendency to volvulus. Consequently intestinal 
obstruction may ensue ; and unless this is relieved by 
high enemata and postural devices, there may supervene 
rapidly a strangulation demanding surgical relief. In 
such case the condition of the patient may permit a 
palliative operation only; the operator may untie the 
obstructing twist and possibly may hold it by sutures 
so that the volvulus will not return. When a patient 
suffers from repeated similar attacks, increasing in 
severity, operation must be done to anticipate strangu- 
lation. At the operation it may be necessary to resect 
a portion of the dilated bowel; for, often, resection 
alone promises a permanent cure. So, after palliative 
operations, one may be obliged to perform a secondary 
operation of resection. 

So much for the operative treatment of intestinal 
prolapse. Let us now consider prolapse of the stom- 
ach, which follows the intestines in their fall. Its 
descent is favored, also, by the weight of its contained 
food, and by the pressure of corsets and bands tend- 
ing to stretch the other supports which hold it in a 
more or less vertical position normally. Consequently 
the greater curvature of the stomach sinks gradually, 
and the organ approaches the horizontal. This new 



ABDOMINAL PTOSIS 305 

position results in its dragging on the pylorus and the 
first portion of the duodenum in such a way that the 
passage of food into the intestine is impeded, and a 
certain amount of gastric motor insufficiency is induced. 
These conditions cause a further descent of the stomach, 
because motor insufficiency results in its being kept 
loaded longer than usual. Gas formation and stomach 
distention result, as well as a frequent tendency to 
hyperacidity with the attendant possibilities of ulcer 
formation. It is said that this last danger is especially 
to be feared when floating kidney is associated with the 
gastroptosis. 

As the general ptosis progresses, the stomach descends 
into the abdominal cavity until its greater curvature is 
well below the umbilicus. What is more to the point, 
for diagnostic purposes, the upper border will then be 
down in the epigastric region below the costal margin. 

What of diagnosis ? What of the significance of 
symptoms ? What of treatment ? In thin persons the 
prolapsed stomach, after a full meal, often may be seen, 
while in the case of others one must distend the stomach 
in order to make it out. Ptosis of the stomach may 
exist without giving rise to any dyspeptic symptoms ; 
indeed, ptosis does not necessarily imply dilatation. 
That a prolapsed stomach may be normal in size can 
be demonstrated by the examination of young and thin 
women. Moreover, moderate motor insufficiency may 
exist without associated dilatation. Frequently, in 
the case of a markedly prolapsed stomach, when dys- 
peptic symptoms are present, they may be relieved 
quickly by a proper diet, proper exercises, and massage. 
One smiles to remember a masseuse chagrined at having 



306 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

pointed out to her the low-lying stomach of a patient, 
whose indigestion and constipation she had cured by 
manipulations. The masseuse should not have been 
chagrined ; the patient's symptoms had been relieved, 
her general condition had been improved by the treat- 
ment ; the prolapsed stomach could now perform its 
functions satisfactorily, and the patient would continue 
well, probably, until upset by some future physical or 
mental strain. One will find gastric dilatation added 
speedily to prolapse in those cases in which dyspeptic 
symptoms are not checked by proper treatment. The 
prolapsed stomach drags on the pylorus so that there 
results a permanent kinking and narrowing of the 
pylorus. These cases of ptosis, plus dilatation, must 
be studied carefully if one would recognize the pres- 
ence of the two associated conditions, ptosis and dilata- 
tion. Evidence of stasis and an increase in the amount 
of hydrochloric acid are present, except occasionally in 
long-standing cases. The capacity of such a stomach is 
increased. Let the clinician note accurately the posi- 
tion of that viscus. 

In the case of such a stomach there exists a genuine 
pyloric stenosis, a stenosis as baneful as that caused 
by a cicatrized ulcer. Some form of operation is 
needed for the cure, and the choice of operation should 
be governed by the rules laid down in a previous 
chapter. 

Moreover, special operations have been devised for 
ptosis of the stomach. The gastrohepatic ligament, 
stretched by the descent of the stomach, has been short- 
ened by Beyea and sundry other surgeons. They pass 
sutures so as to bring the pylorus close up to the under 



ABDOMINAL PTOSIS 307 

surface of the liver. The first suture includes both the 
capsule of the liver and the outer coats of the stomach. 
Beyond this point the gastrohepatic ligament and the 
lesser omentum are infolded so as to raise the stomach 
and make its upper border resume the normal position. 
It is suggested that one should fasten up the colon at 
the same time, else will the stomach lack its old support 
beneath. 

Various other suspending operations have been recom- 
mended and tried, — such as swinging up the stomach 
in an omental hammock, or attaching it to the abdom- 
inal wall ; but no definite and final procedures have 
been perfected. Whatever one does, he risks intro- 
ducing new bad symptoms for those he attempts to 
remedy. In our own experience, gastroenterostomy, or 
the operation of Finney, have yielded good symptomatic 
results in gastroptosis. However, the subject is still in 
an experimental stage. 

Of all the abdominal organs subject to ptosis, the 
kidney receives most attention — more attention, rela- 
tively, than it merits. 

The reason for this undue attention is because kidney 
ptosis is readily discovered. The organ is single and 
distinct. Normally it cannot be palpated, because it is 
situated beneath the diaphragm ; but when prolapsed, it 
is easily grasped. So nephroptosis is made to explain 
many indefinite pains and backaches. Floating kidney 
may be recognized as readily almost as may the dis- 
placed uterus or ovary. Moreover, the floating kidney, 
a single, solid organ, manifestly out of place, offers a 
tempting mark for the enthusiastic operator, who 
shrinks from the difficult task of attempting to re- 



308 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

place and secure other prolapsed viscera, even when 
those viscera are the more pernicious offenders. 

The wisdom of routine operating for nephroptosis is 
in dispute. If one would reach firm ground in that dis- 
pute, one must appreciate and assure himself of the 
frequency of the condition, and one must realize the 
true significance of abdominal symptoms. Doubtless 
the kidney is displaced frequently. Glenard states that 
23 per cent of the female bodies in the Anatomical 
Laboratory at Kiel in one year exhibited a downward 
displacement of the kidney ; in the following year 
nephroptosis was found in 28 per cent of the bodies. 
This is interesting, because for a long time pathological 
anatomists failed to find movable kidneys, though mov- 
able kidneys were recognized by the clinicians daily. 
In a series of two hundred and seventy-two women re- 
cently examined clinically at the Boston City Hospital, 
Larrabee found that one hundred and twelve cases, or 
41.5 per cent, had movable kidneys. At the Massachusetts 
General Hospital, in 1904, Pratt looked for ptosis in all 
cases coming to his clinic, and found that ninety-six, or 
32 per cent, out of two hundred and seventy-one women 
were the subjects of movable kidney. 1 Such has been 
the experience of many others. Nephroptosis in men 
is more frequent than is commonly supposed. Floating 
kidneys have been found in children. 

Frankly, we cannot unreservedly accept Keith's state- 
ment, that floating kidney is dependent on contraction 
of the diaphragm and a consequent narrowing of 
the infra-diaphragmatic space. It is significant, how- 

1 It is interesting that each of these observers, with the same number 
of patients, found thirteen cases in which both kidneys were displaced. 



ABDOMINAL PTOSIS 309 

ever, that a prolapsed hepatic flexure of the colon drags 
its peritoneal attachment down and to the front of the 
lower pole of the right kidney — a fact interesting 
from both an anatomical and a surgical point of view. 
One must remember, also, that the kidney has no proper 
ligamentous supports, and that its close relation to the 
tireless diaphragm renders it a victim to pressure from 
above with every breath that is drawn. Consequently, 
if the liver and diaphragm are prolapsed as a result of 
lax abdominal walls and sagging intestines, there will 
be a constant pounding by the liver, tending to force the 
kidney downward with each respiration. It is well 
known that the left kidney is less prone to wander than 
is its fellow, the proportion being about once for the 
left kidney to ten times for the right kidney. Keith 
explains this by pointing out the close union of the 
spleen and the left kidney ; now, the spleen is held in 
place by a suspensory ligament binding it to the dia- 
phragm. Then, too, the stomach, which descends upon 
the left kidney, is a less heavy hammer than is the 
liver. Moreover, the splenic flexure, even when forced 
downward by a contracted diaphragm, is in a position 
to exert a certain amount of upward pressure ; and 
the splenic flexure moves in and out of the left infra- 
diaphragmatic space according as the stomach is full or 
empty. Certainly the splenic flexure of the colon is less 
likely to be prolapsed than is the hepatic flexure ; hence 
it is a useful supplementary support to the left kidney. 
Most women with movable kidneys are unaware of 
renal disturbance ; such symptoms as they have are 
not referred distinctly to the displaced organ. On the 
other hand, though a patient have a kidney prolapsed 



310 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

in the first degree only, that errant kidney may cause 
severe symptoms. The case is parallel to that of a 
patient with a breaking-down plantar arch of the foot. 
When a foot is beginning to break down, the resulting 
symptoms may be severe enough to call urgently for 
relief. So with a kidney beginning to slip. Rarely, 
indeed, will slight displacements of the kidney require 
operation, but the physician must not forget that opera- 
tion eventually may be demanded. 

When slight displacements cause acute symptoms 
one will find often that the ptosis is due to an in- 
jury, to a fall, a strain or a wrench of the body, or to 
heavy lifting. A prolonged bicycle ride has been known 
to induce this condition. In making the diagnosis, 
assure yourself that the kidney is at fault and that you 
are not dealing with a lesion of the sacro-iliac joint. 

Another aspect of renal ptosis is that presented by 
a kidney long recognized as floating and hitherto harm- 
less, which, on a sudden, causes severe and distressing 
symptoms. The symptoms may be so serious as to 
suggest appendicitis ; and, seen after the acute symp- 
toms have subsided, there may remain so much local 
tenderness as to puzzle the physician and leave him in 
doubt whether the appendix, or the kidney be at fault. 

Clinicians talk of " Dietl's crises " as characteristic of 
floating kidney. Dietl's crises are supposed to be due 
to a twist or kink in the ureter of a floating kidney or 
to a twist in the renal vein. Some experimenters 
believe a twist in the vein to be the more usual cause. 
So they explain these crises by venous stasis rather 
than by acute hydronephrosis. During such laboratory 
investigations no important changes are seen to take 



ABDOMINAL PTOSIS 311 

place in the kidney when the ureter is ligatured, nor 
does the amount of secreted urine vary. But when 
the renal vein is ligatured, the kidney immediately 
increases in size. On the other hand, a number of cases 
have been observed clinically in which the acute symp- 
toms of Dietl's crises were followed by the appearance 
of a fluctuating tumor in the loin, associated with 
marked diminution in the amount of urine passed. 
Then the tumor has disappeared, and concurrently 
the patient has experienced an imperative desire for 
micturition, with the passage of a large amount of pale 
urine. Such is the conflicting evidence. Commonly, 
clinicians credit the attacks to kinking of the ureter, a 
blocking of urine in the pelvis of the kidney, and a 
resulting acute hydronephrosis. Whatever the explana- 
tion, it is a fact that in a number of cases in which 
there is a floating kidney there are repeated attacks of 
pain and distress. These attacks, or Dietl's crises, 
begin frequently with a sense of weight and discomfort 
below the border of the ribs and near the median line ; 
sometimes the first symptoms are pain in that region 
and nausea followed by vomiting. If the symptoms 
persist, the affected area soon becomes tender, so that 
one suspects peritonitis. Often the patient experiences 
palpitation of the heart ; the symptoms become very 
distressing ; sometimes the mental condition suggests 
hysteria. The crisis may persist unabated for several 
days or it may last but a few minutes. Frequently, one 
may replace the kidney and relieve the symptoms by 
removing the clothes, by posture and by manipulation, 
— the patient being in a hot bath if necessary. 

The experienced observer will notice that these symp- 



312 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

toms are similar to those seen in the gall-stone attacks 
caused by a calculus attempting to engage in the cystic 
duct, but not passing out of the gall-bladder. Such 
hepatic colic is relieved usually by measures similar to 
those just described. It is associated with no other 
distinctive features of gall-stone disease, as jaundice or 
tumor of the gall-bladder. 

Keith says that enteroptosis is an important cause of 
gall-stone formation. The descent of the liver carries 
with it the fundus of the gall-bladder, while the neck 
of the gall-bladder and the cystic duct are fixed by the 
gastrohepatic omentum to the central portion of the 
diaphragm — the portion least displaced. The more the 
liver drops, the more it forces down the head of the pan- 
creas and the duodenum, and with the duodenum the 
opening of the common duct. Thus the bile-ducts, held 
firmly at one end and stretched at the other, change their 
relations to each other and to the neighboring organs. 
The cystic duct no longer enters the common duct at an 
angle of about forty degrees, but the two ducts lie nearly 
parallel to each other. There results stasis of bile in 
the gall-bladder, and thus the production of gall-stones 
is favored. We do not agree with Keith, when he says 
that gall-stones are " commonly, if not always, present 
in cases of enteroptosis." We admit, however, that 
gall-stones are frequently found associated with displaced 
viscera. As we have shown, gall-stone colics and Dietl's 
crises may simulate each other. One must differentiate 
carefully. 

Some clinicians have stated that a floating kidney 
may press on the intestine or on the bile passages and 
so cause serious intestinal obstruction in the one case, 



ABDOMINAL PTOSIS 313 

or disabling pain and jaundice in the other. Proof is 
lacking that a kidney ever produces such mischief. 
Transient intestinal and biliary obstruction may thus be 
caused, but severe and protracted disorders probably 
never. 

Recurring renal crises make life a burden. The 
unfortunate victim never knows when or where the 
attack may seize her. When it comes, she must be 
prepared to loosen her clothes, apply heat, and call for 
the masseuse. 

As the prolapsed kidney may come in contact with 
the bile passages above, so it may drop upon the appen- 
dix below. The appendix lies in its path. We have 
told how one may mistake a tender kidney for a dis- 
eased appendix ; more than that, an errant kidney may 
actually irritate the appendix and so cause a chronic 
appendicitis. So we must study carefully the nature of 
recurring pains in the renal-appendix region. Renal 
crises do not kill ; chronic appendicitis may become 
acute and lethal at any moment. 

A. T. Cabot has pointed out that hematuria may 
result from ptosis of the kidney. Sometimes the 
bleeding is profuse and alarming, sometimes it is slight 
but constant. For this symptom of hematuria we 
must operate ; and when we have the kidney exposed 
and in hand, we must look in its pelvis for a small cal- 
careous scale which the X-ray has not shown. 

Once we saw malignant disease developing in a left 
kidney known to be displaced for many years. Such 
cases have been reported rarely. In our case the ptosis 
probably did not cause the malignant growth. 

How anticipate the crises ? Proper bandaging will 



314 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

prevent attacks in many patients ; and when bandages 
fail, we must operate. 

The treatment of floating kidney involves the treat- 
ment of general abdominal ptosis in a great many cases. 
One must study all the symptoms of the patient. 
Often one must perform an exploratory operation in 
order to make a diagnosis. By anchoring the kidney, 
biliary and appendiceal symptoms will be relieved fre- 
quently ; therefore, when the symptoms are complex 
and obscure, it is well to open the abdominal cavity in 
front. Thus mistakes will be avoided. Edebohls ex- 
plores through a lumbar incision for all suspicious 
symptoms in the right side of the abdomen, but his 
method is not satisfactory to the average operator. 

Often one has to ask oneself, Will an operation re- 
lieve these painful renal symptoms? If a patient has 
the general symptom-complex, neurasthenia, let her 
kidney alone, even though kidney symptoms predomi- 
nate. Rarely will the pains of such a neurasthenic 
patient be relieved, for new pains and new symptoms 
will develop in other organs, if not in the region of the 
anchored kidney, and the last state of that patient will 
be worse than the first. Rather should one try first 
the use of supporting bandages in such a case, and ascer- 
tain the condition of the patient's pelvic floor. Build 
up her general health, and do not desperately operate 
for the sake merely of " doing something." 

Now there are certain invalids, few in comparison 
with the number of persons with displaced kidneys, — 
certain invalids who really do have so much trouble 
from persistent hsematuria, from the frequency of their 
renal crises, or from the constant dragging sensation 



ABDOMINAL PTOSIS 315 

and the burning pain along the line of the iliohypo- 
gastric nerve, that they demand operation. The patient 
may indeed be nervous or irritable, — what wonder ! — 
but the pain and discomfort are constant and are found 
in the same location always. The true neurasthenic ele- 
ment is lacking. Such a patient may be a permanent 
invalid, nearly bedridden, always debarred from pro- 
longed exertion, and cut off from the possibility of 
earning a livelihood. Operation will generally relieve 
the sufferer, and her chance of cure by operation is very 
good indeed. 

These severe cases of renal ptosis often may be 
relieved, however, by bandages and pads, which are 
serviceable in the treatment of other forms of abdomi- 
nal ptosis. In these cases the bandage is an appli- 
ance scorned by the many and properly used by the 
few. Yet all surgeons should understand its use. They 
must employ it in most cases, for most cases, especially 
complicated cases, do not lend themselves to operation. 
Certain surgeons argue that a band compressing the 
lower part of the abdomen, or a pad in front of the 
kidney, cannot possibly push the prolapsed organs or 
organ into place. Surely such reasoning is true, but it 
is beside the mark. The man who makes such state- 
ments disregards or fails to comprehend the nature of 
visceral ptosis. Moreover, in many cases physicians do 
not apply these apparatus skilfully or intelligently. 
One must replace the prolapsed organs before applying 
the bandages. A surgeon does not attempt to 
bandage a dislocated shoulder before he reduces the 
displaced bone. In bandaging for ptosis the surgeon 
must use the same pains and nice care that he 



316 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

would use in fitting any other piece of orthopaedic 
apparatus, 

In order to replace the prolapsed abdominal organs, 
lay the patient on her back, with the hips elevated, — 
in a modified Trendelenburg position ; manipulate and 
knead the organs into place, — stomach, kidney, or 
intestines ; and then bind them in position with the 
bandage. 

What bandage shall be used ? There is the difficulty. 
There has been a great deal of discussion of that ques- 
tion, and experiment and failure to find the correct 
bandage. Here is a simple device, which we have 
found satisfactory invariably : Apply a roller bandage 
to the abdomen just as one would apply a roller band- 
age to the shoulder. The abdominal roller should be 
of flannel or canton flannel, cut straight, six inches wide 
and from six to ten yards long„ Before beginning to 
apply it, see that the patient is properly elevated and 
that the viscera are rolled up towards the diaphragm. 
Begin bandaging by taking a binding turn about the 
patient's thigh ; then quickly, smoothly, and firmly 
bandage the abdomen from pubes to ensiform. The 
bandage must lie fairly tight at the bottom of the 
belly, but looser at the top. It fits perfectly ; it feels 
snug and secure. The patient will experience relief 
almost instantly. 

If this bandage is satisfactory and the patient wishes 
to go on with such treatment, the physician may have 
constructed an easily applied belt, but the patient will 
find no apparatus so comfortable as the simple roller 
bandage. The straight-front corset, properly fitted, is 
favored by many clinicians and is very successful. 



ABDOMINAL PTOSIS 317 

There remain a few cases which bandages do not 
relieve ; in which, if the kidney obviously is at fault, 
and its fixation is demanded, the surgeon had best 
operate. He should approach the renal region through 
a flank incision. We shall not dwell on details of the 
various operations. Sundry operators laud sundry 
methods. We follow the method of partial enucleation 
and capsule-stitching prescribed by Edebohls, and we 
are satisfied., 

Wise surgeons insist that the kidney must not be 
replaced and stitched high. That is rational advice, for, 
though one may not agree with Keith in all his conclu- 
sions, especially as regards the clinical significance of 
many symptoms, nevertheless he demonstrates clearly 
that an important factor in the production of ente- 
roptosis is the contracted infra-diaphragmatic space. 
Consequently, with each breath the liver is forced 
downward against the underlying organs. Clinical 
observations show that simple displacement of a kidney 
rarely suffices to provoke severe symptoms; other factors 
must be present if serious trouble is to result. So we 
attain no important end if we replace the kidney in its 
normal position ; while by anchoring it low, we relieve 
it from the hammering of the liver. 

So much for floating kidney. It is a subject fre- 
quently debated, and surgical dust-bins groan with the 
discussion. 

The spleen, too, may drop. It is supported in part by 
the costocolic ligament, which lies beneath it ; it is 
fastened to the left kidney by the ileorenal ligament. 
Furthermore, it is joined to the stomach by the gastro- 
splenic omentum. Frequently the spleen is sq enlarged 



318 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

as to appear beneath the border of the ribs ; but it has 
little tendency to " wander." If a rare wandering 
spleen does exist, it still more rarely gives rise to spe- 
cial symptoms demanding treatment. However, some 
serious cases have been reported as causing annoying 
symptoms, so that the operation of splenectomy had 
to be done. Halsted has replaced at operation the 
wandering spleen several times and has fixed it by 
gauze, packed in below to promote the formation of 
adhesions. 

The liver occupies a unique position in relation to 
abdominal ptosis, for it participates to a certain extent 
in nearly all these displacements, and doubtless hastens 
by its bulk the descent of other still resisting organs. 
The movement of the liver under such circumstances 
is downward and forward, and involves a certain 
amount of rotation on its axis. The right lower border 
is crowded down till it extends below the margin of 
the floating ribs. Much of the substance of the liver is 
found to lie beyond the border of the ribs, well out in 
the abdominal cavity. In spite of this displacement 
from its normal position, rarely is the mass of the liver 
found to be distinctly movable. In most cases the 
large and strong supports maintain their relative posi- 
tions and the organ cannot often be described as " float- 
ing," as one would say of the right kidney. In certain 
rare instances, however, true floating liver is found. The 
organ is then distinctly movable and gives rise to symp- 
toms which can be remedied by operation only. Sun- 
dry denuding and suspending operations on the liver 
have been tried, but none has been found entirely satis- 
factory as yet. 



ABDOMINAL PTOSIS 319 

The pancreas has been thought to be concerned little 
with general ptosis. To be sure there is that dispute 
between Glenard and Ewald as to the interpretation of 
a band felt to lie across the spinal column in front ; is 
it the collapsed transverse colon or is it the pancreas ? 
At any rate all observers agree that the body of the 
pancreas generally remains immovable. Rarely, how- 
ever, when the liver is forced downward, the duodenum 
may be crowded before it and at the same time the head 
of the pancreas may be carried almost to the brim of 
the pelvis. All that is a serious business, and opera- 
tions done hitherto for such grave derangements have 
been palliative mostly, and not altogether satisfactory 
at that. 

Finally, note this, that as yet the only operations 
which are generally recognized as giving complete relief 
in cases of marked enteroptosis are operations on the 
kidney and on the stomach. 

As for the broad subject of abdominal ptosis, we 
have dealt with it in outline only. Until recently few 
surgeons were concerning themselves with the matter, 
though internists were keenly alive to its importance. 
We hope we have shown that enteroptosis is a condi- 
tion common and grave, and that it offers a field for the 
activities of the surgeon as well as of the physician. 



CHAPTER XII 

THE APPENDIX VERMIFORMIS 

Of all the abdominal organs concerned with diges- 
tion, the appendix vermiformis, probably more often 
even than the stomach, is the seat of serious disease. 
Before its capacity for mischief became thoroughly 
understood, it was thought that inflammation of the 
appendix is comparatively rare, and it is well within 
recent memory that European writers referred to ap- 
pendicitis sceptically as the American disease. But 
our present better knowledge of the danger lurking in 
that little organ has taught us that frequently its dis- 
ease processes are latent and obscure, that the symp- 
toms are often misleading and the diagnosis difficult, 
that obstinate dyspepsias and prolonged ill health have 
their origin in the inflamed appendix, and that chronic 
appendicitis especially, for that is the subject of this 
chapter, 1 is a very real thing and a very proper term. 
Deaver 2 says, " Every appendix which has once been the 
seat of inflammation is the seat of interstitial changes, 
and except in the rarer cases of hydrops or when 
adhesions are present, the organ is harmless until an 
acute process is engrafted upon it." But adhesions 
are nearly always present when once the appendix has 
been inflamed, and interstitial changes have sequelae out 

1 The writers cannot accept Deaver's dictum, " The expression ' chronic 
appendicitis ' has also but little meaning." American Medicine, Oct. 17, 
1903. *lbid. 

320 



THE APPENDIX VERMIFORMIS 321 

of all proportion to the apparent extent of those 
changes. 

As has been pointed out by a careful observer, 1 the 
relation of the appendix to the alimentary canal and the 
peritoneum must be borne in mind in this discussion. 
In the process of development or retrogression the 
appendix has been tucked back out of harm's way, com- 
ing to rest upon the posterior and inner surface of the 
caecum in a deep and well-marked fold, which approaches 
the completeness of a pocket or pouch in the perito- 
neum ; hence inflammations of the organ tend to remain 
localized, and the omentum glues over the beginning 
process, wrapping around the inflamed appendix. 
Whereas in the foetus the appendix constitutes a very 
considerable organ as compared with the caecum, at 
the fourth month of intra-uterine life its proportion to 
the caecum being about as one to five, at birth it approxi- 
mates to the adult form and size, its proportion to the 
caecum being about one to fifteen. As infancy and youth 
advance this disproportion becomes more and more 
marked, until the caecum has overgrown and crowded 
the appendix to such an extent that the latter has 
become pushed upward, backward, and usually inward 
so as to appear as a mere spiral projection from the 
posterior aspect of the caecum. This position it reaches 
about the fifth year. 

After this the developmental changes produce no 
further disproportion, but other changes go on. Although 
the appendix does not diminish further in size, a steady 
and constant obliteration of the function of its mucous 

1 Woods Hutchinson, " Appendicitis as an Incident in Development." 
American Medicine, Aug. 1, 1903. 

T 



322 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

coat continues through life. These observations are 
Hutchinson's, and he quotes " Ribbert and other anato- 
mists" to show that there is a steady increase in the 
percentage of obliterated appendices with each succes- 
sive decade of life. By the thirty-fifth year this has 
reached 25 per cent of all cases. By the forty-fifth year 
nearly 50 per cent are occluded, by the fifty-fifth year 
60 per cent, and by the sixty-fifth year nearly 70 per 
cent. Obviously these figures correspond closely with 
the age liability to appendicitis, increasing from child- 
hood to about the thirtieth year, and after that dimin- 
ishing steadily as more and more of the appendices 
become occluded. And these obliterations of the ap- 
pendix are not, as was first thought, due to a normal 
process of involution, for every surgeon of experience 
frequently has seen at operation or at autopsy evidences 
of old inflammation : scars, bands, adhesions, the disap- 
pearance of normal peritoneal folds, and not infrequently 
segments of the appendix actually cut off, as it were, 
and lying free as foreign bodies in the mesentery. 

From such observations, and from the immense clini- 
cal experience now at our command, may we not con- 
clude that a large number of cases of mild appendicitis 
are recovered from permanently ? Though in youth, as 
we know, recurrences of acute attacks are common and 
to be expected, even so Fenger has found that about 
one-third of the severer type of cases show no recur- 
rence. 

With this statement of what appear to be well- 
authenticated facts, it seems as though we were often 
justified in regarding appendicitis as a chronic disease 
clinically, and subject to acute exacerbations. The 



THE APPENDIX VERMIFORMIS 323 

inflammation may not always be active, but symptoms 
are very constantly present ; and it is proper, therefore, 
to include the condition among chronic digestive dis- 
orders. 

As Kelly has recently brought home to us, appendi- 
citis is no new thing, and other writers, notably Ede- 
bohls, 1 have collected a voluminous literature. But 
nearly twenty years ago Fitz told how Saracenus in the 
seventeenth century described an appendicular abscess, 
though its meaning was not apparent to him, and how, 
in 1759, Mestivier of Bordeaux wrote of a perforated, 
diseased appendix found at the bottom of an abscess 
cavity. Kelly has described the same case as well as 
that of one Joubert Lamotte, a French medical student, 
who reported in 1776 finding a " petrified foreign body " 
in the appendix of a person who had died of tympanites. 
Kelly goes on to relate the early writing by Jadelot in 
1808 on the subject, and by Wegeler in 1813. In 1824 
there appeared a paper by Louyer-Villermay, entitled 
" Observations to serve for the History of Inflamma- 
tions of the Caecal Appendix." In this paper he related 
two typical cases, each with the necropsy, and Kelly 
properly concludes that to Louyer-Villermay belongs 
the honor of having been the first to point out the im- 
portance of appendicular inflammations. Three years 
later, in 1827, Melier published a memoir on the subject, 
based on a case of his own, on a study of two others 
detailed by Louyer-Villermay, and on two new cases. 
He described the lesions in the appendix, and even had 
a notion of the possibility of surgical intervention. 

1 G. M. Edebohls, " A Review of the History and Literature of Appen- 
dicitis," in New York Medical Record, Nov. 25, 1899. 



324 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

These ideas did not find favor with Dupuytren, then 
the great surgical authority in France. But it is not 
probable that the negation of Dupuytren himself placed 
any serious obstacle to surgical advance in this field. 
Our art was not then ripe for operations within the 
abdominal cavity. In the forties, the Englishman Han- 
cock advocated opening abscesses in the right iliac fossa, 
and in the sixties Willard Parker of New York elabo- 
rated the procedure. Numerous other surgeons, espe- 
cially in America, pursued the same line of work ; but it 
remained for Fitz, 1 in 1886, finally to explain the condi- 
tions present, and to establish the rationale of operative 
measures. And be it noted that his paper was founded 
on post-mortem observations, and was published at the 
exact fructifying moment when surgical thought was 
centring upon the subject, and in the midst of the new 
era of abdominal surgery made possible by the general 
adoption of antiseptic methods. For McDowell and 
Marion Sims, pioneers in pelvic surgery, were needed, 
with Lister, before surgeons began to mount upward 
in their operating; and in that upward trend toward 
the diaphragm after leaving the pelvis, the appendix 
was the first diseased organ to be attacked. 

The influence upon digestive processes of the ap- 
pendix long diseased has been apparent only in recent 
years, but that attacks of severe inflammation in the 
caecal region have been recognized for centuries we 
know ; for in addition to the cases already cited do we 
not read of that often quoted "Essay on the Iliac Pas- 

1 " Perforating Inflammation of the Vermiform Appendix, with 
Special Reference to its Early Diagnosis and Treatment," R. H. Fitz. 
(Read before the Association of American Physicians, June 18, 1886.) 



THE APPENDIX VERMIFORMIS 325 

sion," written by Thomas Cadwalader of Philadelphia 
in the first half of the eighteenth century ? Fitz quotes 
Goldbeck's thesis, published in 1830, in which Goldbeck 
adopted the French view and used the term "perityph- 
litis," and also quotes John Burne of London ; but among 
them all the causative function of the appendix in pro- 
ducing these inflammations went mostly unperceived, 
and so Fitz goes on with the following words, which 
have become historic, and mark the first use of the name 
of one of the commonest of diseases, " As a circum- 
scribed peritonitis is simply one event although usually 
the most important in the history of inflammation of 
the appendix, it seems preferable to use the term < Appen- 
dicitis ' to express the primary conditions." He proceeds 
to point out varieties of appendicitis, to indicate certain 
of the well-known pathological changes, and to quote 
certain remarkable observations of others, notably those 
of Toft, as referred to by With, in which Toft stated 
that he had found the appendix diseased in one hundred 
and ten out of three hundred autopsies, every third 
person, by his estimate, thus possessing a diseased ap- 
pendix, — an interesting statement to have been made 
twenty-five years ago, when we compare it with the 
findings of Hutchinson and Ribbert already mentioned. 
In the early days, when we were still talking about 
perityphlitis, and when the importance of the appendix 
itself was not fully recognized, surgeons were already 
operating for abscesses in this region ; and Willard Par- 
ker, in 1867, was the first boldly to seek drainage for 
these collections while the pus was still deeply seated, 
but he sought it by a low incision and along the so- 
called extra-peritoneal route. It was John Homans, a 



326 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

pioneer in ovarian surgery, who was the first, in 1887, to 
open an appendix abscess directly by the trans-peritoneal 
route. 

It is not the purpose of the present writers to enter 
upon an elaborate discussion of the pathology and oper- 
ative methods employed in acute appendicitis, as that 
subject is scarcely within the limits of our title ; but 
it is interesting to note the stage at which the recent 
discussion of treatment has arrived in the writings of 
certain surgeons in this country. 

From the time of Fitz's first publication on the 
subject two apparently opposing views have been held 
regarding the initial treatment of acute appendicitis. 
At first and in a great majority were those practitioners, 
both physicians and surgeons, who maintained that 
early surgical intervention was a great risk, that by 
early intervention the patient's life was needlessly jeop- 
ardized, and that the time to operate was after a well- 
defined abscess had been formed. There were those 
who went still farther and asserted that practically all 
cases could be cured by the old-fashioned medical means, 
— opium, poultices, and a limited diet. These last con- 
servatives soon became a discredited minority, and the 
attitude of those opposed to early operation centred 
more or less upon the proposition that the inflamma- 
tory process could be checked and eliminated by poul- 
tices and saline catharsis ; for they argued that by such 
means drainage was brought about through the natural 
channels. However, if an abscess formed later, they 
would open it. Traces of this line of argument are still 
to be found at times, but sound practitioners have long 
abandoned it, if indeed they ever entertained it. It 



THE APPENDIX VERMIFORMIS 327 

needs but a glance at a perforated, inflamed appendix, 
pouring out its poison into the surrounding tissues, to 
appreciate at once how frightfully dangerous would be 
any treatment calculated to increase this outpouring. 
On the other hand, beginning with a small but zealous 
band of radical operators, there has developed a class of 
surgeons who feel that every case of appendicitis should 
be operated upon as soon as seen, unless it is obviously 
quiescent and the patient convalescent. This attitude 
is well expressed in a paper published by Deaver, 1 in 
1903 : " It suffices to say that even a hasty glance at the 
case records tells again the old and oft-repeated story. 
The mortality is in direct proportion to the extra-appen- 
dicular involvement, the latter being dependent upon the 
duration of the disease and the character of the infec- 
tion. While every surgeon of experience is urging the 
need of early operation and impressing the evils of de- 
layed operations upon the general practitioner as well 
as many surgeons, yet, nevertheless, case after case is 
sent to us, reeking with pus or slimy with exudate. 

" The peril of waiting for the interval is not only due 
to the evil caused by the accumulating pus, but, in a 
far greater measure, to the danger into which such 
teaching may lead the medical man or layman. ... If 
immediate operation were universally practised, there 
would be no necessity to devise methods to restrict the 
spread of infection. In the early hours of the attack 
the removal of the diseased appendix eliminates the 
source of infection before the latter event has taken 
place, and the surgeon has merely treated a case of 

1 "One Year's Work in Appendicitis," by John B. Deaver, American 
Medicine, Oct. 17, 1903. 



328 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

appendicitis, a trifling matter and not one of virulent 
peritonitis. ... I conclude with the tiresome but 
necessary statement that an early operation, preferably 
in the stage of appendiceal colic, is the only rational 
procedure and is the only treatment which will reduce 
the mortality in acute appendicitis to insignificant 
figures." 

Deaver's paper is founded upon five hundred and 
sixty-six cases, and the mortality by such treatment as 
he advocates is shown to be 5.3 per cent. He summa- 
rizes in the following two interesting tables : — 





Table I 






Peritonitis, general 


. 


16 


5 deaths 


31% 


Abscess cases 


. . 


183 


22 deaths 


12% 


Appendicitis 


• • 


367 


3 deaths 


0.8% 






566 


30 deaths 


5.3% 




Table IT 






Adults, acute 


, . 


344 


26 deaths 


7.56% 


Adults, chronic . 


. . 


164 








Children, acute . 


• • 


49 


4 deaths 


8.16% 


Children, chronic 


• 


9 

566 


30 deaths 







5.3% 



It appears that Deaver operates in all cases of acute 
appendicitis as soon as they are seen, for he divides his 
list into three classes upon all of which he advises an 
immediate operation : first, general or diffused peri- 
tonitis ; second, cases of localized abscess ; third, cases 
in which the disease is confined to the appendix. 

The foregoing statements of Deaver represent the 
positive views of those surgeons who would operate at 
once. A modification of these opinions is advanced by 
another sound and experienced surgeon, Willy-Meyer, 1 

lu What can we diagnosticate in Acute Appendicitis?" American 
Medicine, April 11, 1902. 



THE APPENDIX VERMIFORMIS 329 

who says that unless he finds immediate indications 
for operative interference he places a patient with a 
pronounced first attack under the most careful ob- 
servation. In pronounced second attacks immediate 
operation is urged. If within the first twenty-four or 
forty -eight hours after the onset of the first acute attack 
the patient's pulse goes up to one hundred and sixteen 
or one hundred and twenty and remains there for 
several hours, and if the pain and tenderness are pro- 
nounced, an operation is performed at once.' A high 
temperature is another indication for operating ; and 
most surgeons would add to this a rising leucocytosis, 
especially if above fifteen thousand. Willy-Meyer says 
further that with a moderate temperature, rapid pulse, 
and marked pain and tenderness, and particularly if a 
chill occurs, he proceeds with the operation. " The 
surgeon must also be somewhat guided by the general 
appearance of the patient," but it is his custom to 
operate when in doubt. The converse of all this is 
that when the familiar signs of appendicitis are abating 
and the picture is improving, he withholds his hand. 
Such are the statements of two surgeons of recognized 
position, and they represent fairly well the attitude 
of a large class in this country. Though there is 
apparently a slight divergence in their views regarding 
the choice of time for operating, it is probable that if 
they were confronted with identical cases at sundry 
times, their opinions and advice would generally be in 
accord. 

At the same time that such practice has become 
widespread, so that it is regarded by the mass of the 
profession and by the intelligent among the laity as 



330 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

conservative practice, it must have been constantly 
evident to a critical observer of surgical opinion that 
such practice has never met with the unqualified ap- 
proval of all thoughtful operators. The novelty of 
many of the situations presented, the long-existing un- 
certainty as to the anatomical conditions actually pres- 
ent with a definite set of symptoms, the sentiment 
that there is much yet to learn, and that we are still 
feeling our way, — all this has made certain men doubt 
at times whether immediate operation, in all cases 
and at all stages of acute appendicitis, invariably was 
justifiable. 

This sentiment found voice through A. J. Ochsner of 
Chicago, first at the Saratoga meeting of the American 
Medical Association in 1901. The procedure he advo- 
cated has come to be known as the " Ochsner treat- 
ment," though indeed it is but an elaboration of views 
widely held, but condensed, defined, and brought to a 
rational perfection by their present advocate. 

Ochsner said again in 1903 : 1 " This form of treatment 
cannot supplant the operative treatment of acute appen- 
dicitis, but it can and should be used to reduce the 
mortality by changing the class of cases in which 
the mortality is greatest into another class in which the 
mortality is very small after operation. 

" I wish to say here, as I have said everywhere before, 
so long as the infection is within the appendix when I 
make the diagnosis, I operate immediately if I can 
obtain the consent of the patient. 

"There is, however, a time which comes to every 

1 Statement by A. J. Ochsner ; Meeting American Medical Association, 

New Orleans, 1903. 



THE APPENDIX VERMIFORMIS 331 

surgeon, when we cannot say with any degree of cer- 
tainty that the particular patient under consideration 
will get well if we operate at once. This class of 
patients, under the best possible conditions and with 
the best possible surgeons, will produce a mortality of 
from 15 to 30 per cent if they are operated on at once 
as soon as the diagnosis has been made. I wish to say 
that with those cases we do not know what will hap- 
pen if we operate at once. We do know, however, that 
in 97 per cent of all such cases suffering from perfora- 
tive or gangrenous appendicitis the patient will get 
well, provided we follow out the plan outlined in the 
above conclusions, namely, that of washing out the 
stomach, and giving absolutely no cathartics and no 
food of any kind by mouth and giving no large enemata 
until the patient has been normal for at least four 
days." 

Woods Hutchinson, in his article already quoted, 
argues that from the anatomical relations of the appen- 
dix we must conclude the " Ochsner treatment " to be a 
rational one, " for Ochsner's series shows a mortality of 
barely 4 per cent, while Deaver's was between 14 per 
cent and 15 per cent." This statement illustrates 
merely the unreliability of statistics and of conclusions 
from a few cases, for in 1903 Deaver's mortality in a 
larger number of cases was but 5 per cent. 

The writers believe that, on the chances, most compe- 
tent surgeons would agree early cases should be oper- 
ated upon at once, that abscesses should be opened, that 
general peritonitis should be drained, and that from 
chronic cases the appendix should be removed. The 
discussion really centres about those acute cases which 



332 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

have entered upon the third or fourth day of the dis- 
ease. We believe that in these cases most surgeons 
would watch the case for a few hours, while employing 
the " Ochsner treatment " ; that if pain, rigidity, spasm, 
fever, pulse-rate, and leucocytosis increased or failed to 
mend, they would operate ; but that if improvement 
were obvious, they would delay operation until a local- 
ized abscess had formed or until " the interval." 

Supremely interesting as is the consideration of acute 
appendicitis, that condition must be regarded for our 
purposes as an incident merely in the course of a relaps- 
ing or chronic appendicitis, which is truly one of the 
most fruitful causes of certain digestive disorders. A 
case from our list will illustrate what is meant. Some 
four years ago there came under our care a college stu- 
dent, twenty-one years of age. He was a robust, well- 
developed, athletic young fellow, a football player, of 
excellent habits and wholesome mode of life. Three 
years before we saw him he was supposed by his physi- 
cian to have contracted malaria. Every six or eight 
weeks he had for four or five days attacks of malaise, 
with headache, slight pyrexia, occasional nausea, and 
general abdominal discomfort. Between these attacks 
he regarded himself as well, but he confessed to a deli- 
cacy of digestion, — hearty meals distressed him, — and 
an irregularity of the bowels with alternating periods 
of constipation and diarrhoea. These conditions had 
continued without especial change. The young man 
had sought various advice, had travelled in search of 
health, and had lived in sundry places. Finally, during 
one of his remissions he happened to consult us, when 
on a careful abdominal examination a sensitive, not 



THE APPENDIX VERMIFORMIS 333 

painful, point repeatedly was made out in the right iliac 
fossa. Convinced that his appendix was at fault, even 
if it was not the source of the trouble, we removed it. 
The patient's recovery of health was prompt and 
permanent. 

In such cases as this the patients will assure you 
after the operation, as time elapses, that they never felt 
so well before ; that they have a sense of well-being 
hitherto unknown; that they feel stronger every year; 
that they are now entirely free from all dyspeptic symp- 
toms or irregularities of the bowels, and other such 
comforting statements. Of course, examples like the 
one above cited are not typical of all cases of chronic 
appendicitis. It is impossible to determine how large a 
ratio they bear to the whole number, but they are com- 
moner than most physicians appreciate. The more gen- 
eral understanding of chronic appendicitis conceives of 
that class which is often and perhaps more properly 
called relapsing appendicitis, and even this class has not 
received that attention it deserves. The writers of text- 
books refer to it rather casually, while they devote 
chapters to the acute form of the disease. Says Osier : 
" The patient gets well, . . . then in three or four 
months he again has signs of local trouble. The attacks 
may recur for years. The cases which recover with the 
persistence of an induration or tumor mass are most 
prone to relapse. There are more severe cases, in which 
the intervals between the attacks are very short and 
the patient becomes a chronic invalid. The frequency 
of recurrence is difficult to estimate. Fitz places it at 
44 per cent, Hawkins at 23.6 per cent." 

The liability to relapse in appendicitis has long been 



334 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

recognized. More than twenty years ago Pepper 1 
mentioned it. In 1885 Whittaker, writing in Pepper's 
" System," said, " In all cases relapses are very frequent, 
as repeated occurrences of the disease constitute the rule ; 
... a case may terminate fatally in a few days, or may 
extend itself over months, or with its effects over 
years or for life." 2 

In the case of the football player there had been no 
severe acute attacks, — indeed, it seems scarcely correct 
to call the case " relapsing " ; but there was a marked 
degree of invalidism, which was terminated by removal 
of the appendix. The conditions found inside the 
abdomen differed very little from the normal. All 
the organs appeared sound, even the appendix itself. 
But it was attached to the ileum by a single stout 
adhesive band, and the mucosa and muscularis were 
infiltrated and thickened near the tip. 

That matter of adhesions is interesting and important. 
Often on gross inspection nothing except adhesions is to 
be made out. In the early days of these operations one 
used to hear surgeons say : " That is a normal appendix. 
There is nothing there but a few adhesions." Now, 
adhesions mean very definite conditions. They mean a 
previous inflammation and the possibility of another; 
but more than that, usually they mean present and per- 
sistent discomfort, pain, dyspepsia, irregularity of the 
bowels, and impaired health. And these symptoms are 
due to mechanical causes. An appendix tied up to the 
colon, the mesentery, the omentum, the ileum, or the 

1 " Contribution to the Clinical Study of Typhlitis, etc." Transactions 
Medical Society of Pennsylvania, 1883. 

2 The older statistics of Volz made relapses 80 per cent of all cases. 



THE APPENDIX VERMIFORMIS 335 

brim of the pelvis, tends to restrain the normal move- 
ments of those organs, and more especially it limits the 
proper distention of a loaded caecum. The dilated 
bowel drags upon the appendix, pain and a train of 
reflex symptoms are caused, and the patient seeks com- 
fort by the use of laxatives, stomachics, and tonics, all of 
which give him but temporary relief at the best. He 
comes to regard himself as a confirmed dyspeptic. 
He becomes the despair of the doctors, if the true 
condition be not ascertained ; and he drags on a more 
or less wretched existence, a weariness to himself and in 
danger of falling a victim to an acute and possibly fatal 
appendicitis. This picture is one which has now become 
familiar to all physicians of large experience, and the 
following cases will serve to illustrate more vividly the 
apparently trifling conditions which may bring a person 
into such a state of ill health. 

I. A young girl of seventeen, with stomach-ache and 
chronic constipation, consulted us. She said that every 
three or four days she found herself severely constipated, 
though on the intervening days her bowels moved 
regularly. The constipation was associated with grum- 
bling pain for several hours in the umbilical region. 
An enema usually brought a movement associated with 
increased general abdominal pain, subsiding in about an 
hour. These conditions had existed for some two years. 
Of late her appetite had become capricious and food 
amounting to a " square meal " always distressed her. 
She was losing flesh and strength, her catamenia were 
becoming scanty and irregular, and she was thought 
to be " in a decline." 

Careful observation of the case and repeated exami- 



336 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

nations of the abdomen convinced us that her appendix 
was at fault. The stomach was of normal size and 
position, an analysis of the gastric secretions and an 
investigation of the motility revealed nothing. The 
pelvic organs were sound, and except for a rather 
abnormal tympany, the intestines appeared to be as they 
should. 

There was present, however, a constantly palpable 
appendix which was distinctly tender when rolled under 
the fingers. 

The abdomen was opened ; the appendix found 
lightly adherent to the ileum, kinked in the centre, 
and slightly indurated toward the tip. It was therefore 
removed. 

The report of the pathologist stated, " The appen- 
dix was 5.5 centimetres long, somewhat thickened with 
adhesions toward the tip ; chronic appendicitis." 

This young girl made a prompt recovery. The action 
of her bowels became regular and normal, pain disap- 
peared, her appetite returned ; she gained twenty pounds 
in six months, and now after a year she is perfectly well. 

II. A lad of twelve, a schoolboy, in comfortable 
circumstances, came to us with his mother about a 
year ago. The story was that, though well grown and 
vigorous, he had occasional attacks of constipation, for 
which castor oil was required ; and that accompanying 
this condition there was usually excruciating frontal 
headache. On account of these attacks he would lose 
four or five days of school out of every month. 

The case was referred back to the family physician 
with general advice about hygiene of the bowels and 
about cold bathing. 



THE APPENDIX VERMIFORMIS 337 

A month later we were asked to see him m the 
midst of one of these attacks. There was severe head- 
ache, the bowels had not moved for two days, the tem- 
perature was 102° F., and the pulse rate one hundred 
and ten. The abdomen was uniformly tender, but there 
was nothing localized. Eight hours later we saw him 
again. The symptoms continued ; the temperature had 
risen to 103° F., and the pulse to one hundred and forty. 
The leucocytosis was eighteen thousand. There was 
great discomfort and restlessness. At this time careful 
palpation repeatedly practised in the right iliac fossa 
revealed marked tenderness at McBurney's point. 

We removed the appendix at once. Adhesions were 
found, slightly kinking the organ at its middle ; other- 
wise, grossly, it appeared normal. The pathologist 
reported : " The appendix was five centimetres long, 
with many adhesions on the outside. The mucous mem- 
brane was normal. Chronic appendicitis.' , 

The wound was sewed up tight, the lad's convales- 
cence was uneventful ; he was up and about at the end 
of two weeks. 

The operation seems to have banished his headaches 
and constipation. At any rate, they have not re- 
turned. His general health is better than formerly 
and his digestion and bowel action "perfect." 

III. A sea-captain from Cape Cod, fifty-nine years 
old, consulted us about three years ago. He said that 
for twenty-five years he had been a chronic dyspeptic, 
and during his voyages had consumed all the " doctor's 
stuff " on which he could lay his hands. Of course his 
diet, while at sea, was atrocious, but that could not 
be helped. For five years he had "laid ashore," but 



338 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

was worse rather than better. Occasionally he had 
colics in the umbilical and epigastric regions, relieved 
by the passage of much flatus. His diet had little 
bearing on his symptoms. His bowels were always 
constipated, and though he was well developed, his 
flesh and strength were below the normal. 

An examination of the stomach showed that viscus 
to be in its proper place and not dilated. There was 
good motility and the gastric secretions were not ab- 
normal. The thoracic and abdominal organs seemed 
normal, except that there was slight tenderness along 
the right costal margin, and in the right iliac region 
what felt like a resistant mass about the size of a 
lemon. 

An exploratory laparotomy was advised with the ex- 
pectation of finding malignant disease of the caecum ; but 
there was none present, nor was there evident disease 
of the biliary passages. There was found, however, a 
considerable mass of adhesions tying up the caecum and 
appendix in the omentum. When freed, the appendix 
was found to be about three inches long, much thick- 
ened, and nearly cut in two by a band at about its 
middle. The pathologist's report stated merely, " The 
appendix was three inches long, adherent to the omen- 
tum, and much thickened ; chronic appendicitis." 

This case was particularly gratifying for the com- 
plete relief of symptoms which followed the operation. 
The man recovered as promptly as a child, and for 
three years has been well. He eats freely of what he 
chooses, has no dyspepsia or pain, has gained twenty 
pounds, and tells us he feels like a boy again. 

IV. This was the case of a man forty-eight years old, 



THE APPENDIX VERMIFORMIS 339 

and on account of complications was not so satisfactory 
as the foregoing. We had seen him in consultation 
some ten years previously, when he was in the midst 
of an attack of localized left-sided peritonitis, due to 
what we then believed to be a stercoral ulcer at the 
splenic flexure of the colon. He had recovered at that 
time, and his left-side symptoms had long since dis- 
appeared. At the time of which we are now speaking, 
a year ago, he stated that for five years he had had fre- 
quent attacks of "biliousness" with great depression, 
nausea, "bloating," and constipation. Occasionally 
these symptoms would be accompanied by pain in the 
right hypochondrium. He suffered also from headaches, 
confusion, and loss of mental grasp. His ill health had 
forced him to give up his business, and he informed 
us gravely that he would prefer to die rather than 
continue as he then was. 

The physical examination of the case was not very 
satisfactory, and we could not convince ourselves that 
for many of his symptoms he might not be put in the 
category of neurasthenics, — that convenient category 
in which we are wont to shroud so much of our igno- 
rance. However, after watching him for some weeks 
and consulting with a competent neurologist, we became 
convinced that here was a definite abdominal lesion or 
complex of lesions which surgery might remedy. So 
far as our examination went, it discovered an abdo- 
men somewhat distended constantly, slightly tender 
over the whole colon, and markedly tender in the 
right hypochondrium, in which region he indicated 
recurring discomfort and pain. 

Accordingly we operated, making the abdominal 



340 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

wound through the right rectus above the umbilicus. 
Throughout the right side of the abdominal cavity we 
found light adhesions, attaching the colon to the gall- 
bladder, the omentum, and the ileum. The caecum 
especially was implicated, but most interesting was the 
condition of the appendix. At first sight it seemed to 
be represented by a thickened stump merely, about half 
an inch long ; but a further search revealed the re- 
mainder of the organ, cut into three sections by the old 
inflammatory process, — like separated links of a chain, 
each link lying free in the mesentery at an interval of 
from one to two inches from its fellows. On their 
removal these segments of the appendix proved to be 
obliterated, except the proximal stump, in which there 
remained a patent lumen. We completed the operation 
by breaking up all the visceral adhesions. 

The patient recovered slowly. There were no im- 
mediate complications, but the man's health had been 
greatly impaired. However, he was freed of his worst 
symptoms, and in the course of six months found him- 
self perfectly well, save for a hernia which developed 
in the operation scar. But his digestive organs now 
work properly, his mental state is good, and on the 
whole he has been benefited. 

V. A further case was that of a man of twenty-eight, 
a farmer, sound, vigorous, and well nourished in appear- 
ance. For some five years his friends had noticed that 
his disposition was changing. Previously cheerful, 
active-minded, optimistic, he had become silent, retir- 
ing, morose. He never complained of ill health, but it 
was evident that he was suffering from a mental or 
physical ailment. Occasionally he would go all day 



THE APPENDIX VERMIFORMIS 341 

without food, and he was heard walking the floor at 
night. 

In the summer of 1903 he consulted us and reluctantly 
stated that he had long suffered from a confirmed 
dyspepsia. He was constantly depressed and rendered 
miserable by trifles. His surroundings and daily com- 
panions had become irksome and intolerable to him, 
his food frequently distressed him, he was greatly 
troubled with eructations and constipation, and three 
days before he had spent a wakeful night from annoying 
general abdominal pain. 

We had known the man for several years and recog- 
nized the mental condition which he described. A 
routine examination revealed nothing except a rather 
marked abdominal distention, until we came to the 
right iliac fossa, where on deep palpation we were able 
to detect an apparently swollen appendix, which was 
quite tender on pressure. 

After watching the case for a couple of weeks, and 
finding always the tender appendix, we advised its re- 
moval. On opening the abdomen, nothing abnormal 
was discovered except an indurated appendix, slightly 
swollen and adherent throughout its length to the lateral 
aspect of the caecum. The pathologist reported, " The 
appendix was seven centimetres long, of somewhat en- 
larged diameter, with many adhesions throughout its 
length ; upon opening, the lumen was found to be 
obliterated at one end, dilated beyond, and containing 
thick glairy mucus ; obliterating appendicitis." 

Here again, as in nearly all these cases, the conva- 
lescence was uneventful. The patient was out of bed 
on the twelfth day and went home at the end of two 



342 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

weeks. His dyspeptic symptoms disappeared, and the 
action of the bowels became normal. The most strik- 
ing change was in his mental attitude. Two months 
after the operation he had regained his natural cheer- 
fulness, and his friends reported that the " blues " had 
been banished. 

VI. Another instructive case was that of a boy 
thirteen years old. Up to the age of eleven he had 
been a lively, vigorous child, but for two years he 
had been growing languid and timid. His appetite had 
become poor, his physical development had ceased, he 
had become very constipated and was frequently laid 
up in bed with severe attacks of what was thought to 
be « wind colic." 

In this case a diagnosis was not very obvious, and it 
was only after studying him for several weeks and rul- 
ing out other suspected conditions that we decided to 
cut down upon the appendix. That organ was found 
quite normal in appearance, but adherent by its tip to 
the omentum. It was removed and the pathologist 
reported, " The appendix was three centimetres long, 
more or less injected, but otherwise not remarkable." 

We were disappointed in these findings, but the results 
appeared to justify the operation. The lad rallied rather 
slowly, but continued to improve in general health and 
strength during the subsequent two years in which he 
was under our observation. He lost his lethargy, re- 
gained his appetite and vigor, was no longer constipated 
or subject to colics, and eagerly rejoined his comrades 
in their sports. To his parents the change was striking, 
and their satisfaction was proportionate. 

Observe that the pain of chronic appendicitis may be 



THE APPENDIX VERMIFORMIS 3-43 

anywhere in the abdomen, but the tenderness is in the 
appendix. 

These six cases are specially selected, of course, to 
show good results. One is not always so fortunate; but 
on the whole the conditions described are frequently 
met with by surgeons and must be very common in the 
experience of general practitioners. 

These cases show a clinical course quite distinct from 
what is seen in " relapsing appendicitis," as it is prop- 
erly enough designated. Probably many of the cases 
of relapsing appendicitis are truly acute exacerbations 
implanted upon chronic processes, but clinically the 
name is correct enough. The relapsing cases may be 
and often are very similar in their history to those 
chronic cases above described, except that there is 
always the story of definite and severe attacks of pain, 
with pyrexia, rapid pulse, obstipation, a rising leucocy- 
tosis, and tenderness on pressure ; in other words, the 
clinical picture of an acute appendicitis. The process 
does not go on to an extensive involvement of the peri- 
toneum ; the symptoms subside, the local signs mostly 
disappear, and except for some impairment of the gen- 
eral health, the patient regards himself as well until he 
is again attacked. 

Cases of both these classes are dangerous. At the 
best the disease may gradually destroy the appendix as 
a focus of infection and trouble, — a slow process, not 
to be counted upon ; or the patient may expect to go 
on with the sword hanging over him, — never safe from 
day to day, while at the worst an acute attack may 
supervene at any time, with all the dread and danger 
which such attacks involve. 



344 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

The treatment of chronic cases, always, is removal of 
the appendix. It must be so. That is a course safe 
and sure. All other methods, and such are zealously 
advocated especially by certain French writers, mean 
only procrastination, anxiety, and risk. We have yet to 
find the intelligent man who knowingly carries about 
with him a " grumbling " appendix, and does so com- 
placently. 

There are two good methods of reaching the ap- 
pendix in the cases which are not acute, — by the 
McBurney incision, and by the " retromuscular route." 
In both, when all goes well and there are no complica- 
tions, the wound is short — from two to three inches 
— and the resulting scar strong. 

The familiar McBurney incision is made in the right 
inguinal region outside of the semilunar line. The skin 
having been cut, the underlying aponeuroses and muscles 
are split, not cut, until the peritoneum is reached and 
incised. As a result of this method of opening the ab- 
domen, the various split structures fall into place again, 
immediately the restraining retractors are removed. 
Even without stitches, no hernia is likely to result. 
With stitches either " through and through,'' or placed 
in each layer, the wall is left as good as new. The 
McBurney method of incision is ingenious and valuable, 
and is the favorite of many operators of great experi- 
ence. There are two objections to it, — one rather triv- 
ial, the other of importance at times. Except in the 
most practised hands, it is not a rapid method of enter- 
ing the abdomen. When, for any reason, it is necessary 
to enlarge the McBurney incision after the abdomen has 
been opened, there results often a severe mutilation of 



THE APPENDIX VERMIFORMIS 345 

the abdominal wall with the consequent very consider- 
able danger of hernia. 

With many surgeons the retromuscular incision is 
the favorite. The skin incision is made over the middle 
of the right rectus muscle, below the umbilicus, and is 
carried down through the anterior sheath of the muscle. 
Then with a retractor the sheath is stretched outwards, 
the edge of the rectus is seized and drawn towards the 
median line, and the underlying peritoneum is opened 
immediately below the skin incision. So when it 
comes to closing the wound, the rectus muscle falls 
outward again past the peritoneal opening, previously 
stitched up, the anterior sheath of the muscle is united 
in its turn, and then the skin. A sound wall is the 
result, and in the very considerable experience of the 
writers no hernias have resulted. This method of 
entering the abdominal cavity is very rapid, but its 
great advantage is that the opening may be readily 
enlarged to any extent desired, and may be closed sub- 
sequently without change of technique and with a 
resulting scar exceedingly strong. 

The treatment of the appendix stump in these chronic 
and "interval" cases has been a subject of much un- 
necessary controversy. It matters little how you treat 
the stump. One man cuts it off and invaginates it into 
the caecum ; another turns back a cuff of the serosa and 
stitches that over the stump by a purse-string drawn 
about it and through the serosa of the caecum; while a 
third merely cauterizes the mucosa and leaves the 
stump to take care of itself. So far as we have gathered 
the results of these methods, all are equally good. 

It would be interesting to learn the subsequent his- 



346 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

tories of a large number of patients who have been 
operated upon for chronic and relapsing appendicitis. 
We have been at some pains to look up records of eighty 
such cases operated upon at the Massachusetts General 
Hospital and in our own practice, and have added to 
these twenty cases collected from the hospital records 
by F. T. Murphy. In brief it appears that of these one 
hundred cases the outcome may be expressed in the fol- 
lowing table : — 





Pbkfect 


Good 


Bad 


Anatomical Results 
Functional Results 


94 
91 


4 
5 


2 
4 



The " bad " results in these cases were due to adhe- 
sions either about the appendix stump or along the line 
of incision. In all of these four cases secondary opera- 
tions were done with complete relief of symptoms, so 
that the patients are now well. The " good " results 
are cases in which there was no relief of digestive 
symptoms, or in which there were painful scars, and 
those last cases would be improved or cured prob- 
ably by a second operation. There were no cases of 
hernia through the short incisions. 

These results are extremely suggestive and encourag- 
ing. Probably few therapeutic measures undertaken 
for serious conditions in any department of medicine or 
surgery will make a better showing. 

The question of functional results secured after opera- 
tions for chronic appendicitis is interesting as bearing 
upon the question of etiology. Authors have been 



THE APPENDIX VERMIFORMIS 347 

wont to state that constipation and " indigestion " are 
among the prime causes of appendicitis. Lange, 1 for 
instance, regards the disease as very common in this 
country as compared with Europe, and states that this 
is due to our eating too fast and too much, with the 
result that we are a constipated people. Any one who 
has spent a few months in Germany or England may 
have observed that the peoples of those countries are 
trenchermen of no mean capacity, and comparative 
statistics as to national constipation remain to be com- 
piled. Certain it is that of late years we hear almost 
as much of appendicitis in Europe as we hear of it 
in America. Now it is certain that in those cases in 
which constipation and " indigestion " are associated 
with appendicitis, the removal of the appendix com- 
monly is found to be followed by a cessation of both 
forms of digestive disturbance. 

Let us conclude, then, as we seem justified in doing, 
that in a great many cases of chronic dyspepsia, never 
permanently cured by medication or improved hygiene, 
an anatomical cause for the trouble is to be found in 
the appendix ; and let us observe further that in more 
than 90 per cent of these cases appendectomy results in 
the restoration of health. 

1 Editorial in Medical Record, August 1891. 



) 



APPENDIX 



BY 



HENRY F. HEWES, M.D. 

PHYSICIAN TO OUT-PATIENTS AT THE MASSACHUSETTS 

GENERAL HOSPITAL 

AND 

INSTRUCTOR IN CLINICAL CHEMISTRY, HARVARD 

MEDICAL SCHOOL 



APPENDIX 

DIAGNOSIS IN CONNECTION WITH SURGERY OF THE 
STOMACH 

I. The Diagnosis and Significance of Gastrectasis. 
II. The Diagnosis of Cancer and Ulcer of the Stomach. 
III. Record of Clinical Findings in a Series of Cases of 
Stomach Disorder in which Pathological Diagnoses were 
made at Operation or Post-mortem Examinations. 

Introduction 

The general usefulness of surgery as a therapeutic meas- 
ure in certain disorders of the stomach has entailed upon us 
an additional responsibility for the achievement of accuracy 
in the diagnosis of these disorders : first, because the pos- 
session of so useful a therapeutic remedy makes it imperative 
that all cases which are amenable should get the benefit of 
the remedy, and at the earliest possible opportunity ; and 
second, because the employment of this surgical remedy, in 
all conditions, at the most optimistic estimate, being asso- 
ciated with some danger, it is imperative that the greatest 
accuracy possible in the understanding of the conditions 
present should be attained before subjecting the patient to 
this danger. 

A full knowledge of the method and means of diagnosis 
of these special conditions of stomach disease amenable to 
surgical treatment which are at present at our disposal is, 
therefore, an essential part of the equipment of all medical 
men, as well of the surgeon who operates upon the cases as 
of the physician who first sees them. 

351 



352 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

The facts or clinical data upon which diagnosis is based in 
these conditions of stomach disorder may be divided into 
three groups, according to the method of examination by 
which they are obtained. 

They are, first, the facts of the history and subjective 
symptomology of the patient ; second, the findings by or- 
dinary physical examination, — inspection, percussion, and 
palpation of the abdomen, — and study of the general 
physical condition of the body, the existence of emaciation, 
cachexia, or anaemia, for example ; and third, the findings 
obtained by the application of special objective methods of 
diagnosis, — as the examination of the contents expressed by 
the use of the stomach tube for the study of the chemistry 
or motor function of the organ, the study of the size and 
location of the stomach as examined by inflation with air, 
the study of the faeces for evidence of bleeding in the 
stomach. 

With the subject-matter of the first two groups, — the 
details of the history and regular physical examination of 
stomach disorders, — the average practitioner is conversant. 
He can read it in the text-books, and he observes it in his 
cases. 

With the matter of the third group, — the special methods 
of investigation of the stomach, the findings which can be 
obtained by them, and the insight to the understanding of 
the various stomach disorders which may be achieved 
through the use of these methods, — the acquaintance of 
practitioners, even of those of widest experience and ad- 
vanced knowledge, is much less intimate. 

Yet not only are these special examinations a necessary 
part of the study of all cases of stomach disorder, but it is 
from the results of these examinations, in the majority of 
stomach cases, that the most definite determination in regard 
to the nature of the disorder present is made. 

I have, during the last ten years, been making a special 
study of these expert methods of diagnosis of stomach dis- 



APPENDIX 353 

eases, and have collected in this article a brief summary of 
the results of my experience in regard to the value of the 
various findings obtained by these methods, and of the use- 
fulness of the routine utilization of these methods in the 
clinic for the diagnosis of the special forms of stomach dis- 
order which have, up to the present, proved a suitable 
subject for surgical treatment. 

The disorders of the stomach to the relief and cure of 
which surgery lends itself are : — 

(a) Conditions of insufficient drainage of a chronic char- 
acter, from any cause. 

(b) Cancer of the stomach. 

(c) Ulcer of the stomach. 

Chapter I. — The Determination and Significance 
of Insufficient Drainage, or Gastrectasis 

Insufficient drainage of the stomach exists as a condition 
secondary to a variety of causes. Omitting the conditions 
of acute retention, such as occur in acute gastritis or spastic 
stenosis, insufficient drainage means, in the great majority 
of cases, an obstruction of the pyloric opening, from cancer, 
or ulcer, or adhesions, or other cause, or a dilatation of the 
stomach or ptosis of the organ with atony of the walls. 
A few cases have been reported in which the phenomenon 
represented local stagnation in a part of a stomach, — cases 
of hour-glass stomach; or cases of cancer of the wall, where 
bacterial elements were harbored in the surfaces of the 
neoplasm for undue periods, the general motility of the organ 
being normal. 1 

The degree of the mechanical disturbance and the result- 
ing evidences of the condition of stasis vary with the case. 
In cases in which the only retention is that caused by the 
rough surfaces of a neoplasm of the wall, the stomach may, 
to all appearances, empty itself in a normal period, the only 

1 Strauss, Zeitschr. f. klin. Med., Vols. XXYI and XX VTI ; Deutsch. 

Med. Woch., 1896, No. 38, supplement. 
2 a 



354 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

evidence of insufficient drainage being the presence in the 
contents of the stomach of an excessive number of organized 
ferments, with the capacity to cause excessive fermentation. 
The only evidence of stasis in such conditions is the finding of 
one of the fermentation tests (see pp. 355-356). In cases in 
which the general motility is reduced, we have, together with 
this excess of ferment capacity, or sometimes without this 
element, a retention of the ingested food for periods longer 
than normal. This retention of food may be slight, when a 
meal, — a Leube meal, for example, — which should be en- 
tirely emptied from the stomach seven hours after ingestion, 
takes eight to ten hours for the process of evacuation. Or 
the retention may be marked in degree, in which case food 
contents will be found twelve hours or more after feeding. 2 

Whatever the type and degree of stasis, it can always be 
diagnosticated when it exists by obtaining the stomach con- 
tents at a period when, if conditions of drainage are normal, 
the stomach should contain no macroscopic food elements or 
show signs of excessive ferment population. 

The standard period adopted for this test in my investiga- 
tion was one at least twelve hours after the ingestion of the 
food or material of any kind. As the average time of the 
stomach for emptying itself after a full meal, a Leube 
dinner, is seven hours, 2 this twelve-hour period is long 
enough beyond the normal limit to allow for normal varia- 
tion and idiosyncrasy and to show an undoubted disturbance 
of motor capacity. Slight conditions of stasis which may 
be overlooked by this method may be discovered by further 
experiments at eight-, nine-, or ten-hour periods. For a stand- 
ard period for the initial examination in ordinary practice, 
however, that of twelve hours is the most satisfactory. 

The stomach contents, obtained by expression with the 
tube at this twelve-hour period, are called the contents of the 
fasting stomach. 3 

2 Leube, Deutsch. klin. Med., Vol. XXXIII. 

8 It is the rule, even with normal individuals, to obtain some contents 



APPENDIX 355 

To determine the existence or non-existence of insufficient 
drainage (or as it is called in clinical terminology, gastrecta- 
sis), the contents of the fasting stomach should be examined 
for the presence of two elements : (1) an abnormal food resi- 
due, which means the presence of food microscopically- 
recognizable or of a sediment which under the microscope 
turns out to be made up of masses of food ; (2) an abnormal 
ferment contents. If the case is one of stasis, one or both 
of these will be present. 

The first factor, the abnormal food residue, is the more 
constant. It was present in twenty out of twenty-one stasis 
cases of my clinic. 

The fasting contents of the normal stomach, as studied in 
twenty cases, showed no food elements other than an occa- 
sional starch granule or small fragment recognizable under 
the microscope. 

Where a food residue is present, no further search for evi- 
dence of stasis is necessary. If such food residue is absent, 
the contents must be examined for the presence of the other 
stasis factor, an abnormal ferment content. 

The presence of such a ferment content in the fasting con- 
tents may be discovered, (1) by the finding of numbers of 
the organisms known as sarcino3 ventriculi; (2) by finding 
lactic acid ; (3) by finding an excessive yeast fermentation 
capacity in the contents. If any one of these tests is posi- 
tive, the existence of stasis, i.e. of insufficient drainage, is 
proven. If all, in addition to the food test, are negative, 
the condition — that is, a twelve-hour stasis — is absent. 

The sarcinae are recognized by examination of the sedi- 
ment under the microscope. They are but an occasional 
feature of stasis, occurring, as a rule, in association with a 
plentiful HC1 secretion. 

The sarcinse do not occur in considerable numbers in any 
condition other than stasis. 4 

in a stomach twelve hours after a meal, say 5 cubic centimetres to 30 
cubic centimetres. 

4 Qppler, Munchen Mec\. Work, 1894, No. 29, 



356 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Lactic acid is discovered by the following test : To 5 to 
10 c.c. of stomach contents add a drop of HC1, boil to a 
syrup, extract the syrup with 5 to 10 c.c. of ether. Add 
the ether extract to a practically colorless solution of ferric 
chloride. A resulting greenish yellow color shows the pres- 
ence of lactic acid. 

Lactic acid occurs only in those conditions of stasis in 
which the secretion of HC1 is reduced. It is not found 
in the fasting contents, whatever the disease, unless stagna- 
tion is present (vide Notes 18 and 19, pp. 372-373). 

This lactic acid test for stasis is of diagnostic value only 
when it is found in a fasting contents. Here it matters not 
whether the quantity is influenced by the nature of the food 
taken, its content of lactic acid or lactates, or is due entirely 
to fermentation. If present, it means stasis. The presence 
of lactic acid in vomitus, or in contents other than a fasting 
contents, cannot be given such significance unless it can be 
proven that no appreciable amount of lactates or of the acid 
(sarco-lactic acid) was present in the food of the patient. 

The third stasis factor, the presence of yeast fermentation, 
is tested for as follows : — 

Ten or twenty cubic centimetres of contents (according to 
the quantity obtained) is mixed with one-half its quantity of 
sterilized 10 per cent glucose solution. This mixture is 
placed in a fermentation tube, absolutely filling the tube, 
and is placed in a thermostat at 37° to 40° C. 

Any apparatus for determining fermentation may be used 
in the test. I have used a test-tube of a capacity of 20 c.c, 
in which was inserted a rubber stopper carrying a bent glass 
tube which reached to within one inch of the bottom of the 
test-tube. The quantity of fermentation can be judged, in 
such an apparatus, by the amount of the mixture in the tube 
displaced by the gas formed in the fermentation process. 

In performing the experiment the mixture should first be 
observed, if possible, twelve hours after the beginning of the 
experiment ; then at eighteen hours, twenty-four hours, and 



APPENDIX 357 

forty-eight hours, and the presence of fermentation, as evi- 
denced by the quantity of gas formation, should be noted at 
each observation. If no gas formation, or one of very slight 
extent (say one-twentieth of a tube at most), is present 
after forty-eight hours, the result of the test may be regarded 
as negative. If a gas formation of more than one-twentieth 
of a tube is present, the sediment of the fermentation mix- 
ture must be looked at under the microscope. If this sedi- 
ment contains a numerous colony of freshly budding yeast 
spores, the result of the test may be regarded as positive, and 
so the evidence of stasis is confirmed. 

The contents from a normal stomach or from a stomach 
affected with disease, but with no interference with the 
emptying of the contents into the duodenum, have in no 
case, in my experience of over one hundred and eighty con- 
tents studied by this method, given a positive fermentation 
test according to the above standard. We do, in cases other 
than those of stasis, sometimes get by this test a gas forma- 
tion of varying amounts up to three-fourths of a tube in forty- 
eight hours. In fact, in fasting contents which contain no 
free HC1, it is the rule to get a certain amount of gas for- 
mation. But in all these cases, excepting those in which 
stasis is present, the sediment is made up of bacteria, not 
of yeast. In such cases, the bacteria swallowed from the 
mouth are apparently sufficient to cause some fermentation. 
This does not occur with yeast, however, except to the 
extent of the formation of a few bubbles at the top of the 
test-tube, unless stasis exists. I have obtained the bacterial 
fermentation with gas fermentation in vitro with the contents 
from normal individuals. 

The phenomenon of excessive yeast fermentation may, 
according to my records, occur in any contents of a stomach 
with stasis, both in those stomachs with a low acid secretion, 
when it is associated with an active bacterial fermentation, 
or in those with much free HC1. Case VII of my record 
gave both this yeast test and the lactic acid test for bacterial 



358 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

fermentation. The yeast is more characteristic, however, 
of cases in which a combination of stasis with plenty of free 
HQl is present, — cases in which bacterial fermentation is 
not a feature. I have seen it in cases in which the quantity 
of free HC1 was .20 per cent, — that is, hyperchlorhydria 
(see Cases V and XXIII). 

The yeast fermentation test has, like the sarcinee test, one 
special value, — it can be applied to a contents obtained at 
any time. It may, therefore, be possible sometimes to diag- 
nosticate stasis by the use of this test, in emergency cases, as, 
for example, where a vomitus only is obtained or where it 
is difficult to arrange for obtaining the fasting contents with- 
out recourse to the more elaborate preparations necessary for 
obtaining the fasting contents. It must be borne in mind, 
however, that this yeast test, like the sarcinee test, is not 
positive in all casis of stasis. In some cases, for example, 
the fermentation is entirely of the bacterial type, the test 
for which is the lactic acid test in fasting contents. So that 
the fermentation test must not be used for ruling out stasis, 
though it may always be used for ruling it in. 

These tests for ferment elements are supplementary tests, 
for use on occasions when, as a rush measure, or through 
inability to obtain fasting contents, examination is made on 
contents after a meal, or from vomitus ; or in cases in which, 
upon examination of fasting contents, the regular test, the 
food residue, is lacking. 

This first use of these supplementary tests depends upon 
the fact that two of these tests, the sarcinee and the yeast 
ferment tests, can be determined in vomitus or contents 
after a meal, as well as in a fasting stomach. This is not 
always true of the regular food test, which in many cases of 
stasis is undeterminable in contents obtained within six 
hours after a meal. We may, therefore, by the use of the 
sarcinse or yeast test, be able to make our diagnosis of stasis 
without recourse to the fasting contents. It must be borne 
in mind, however, that these two special tests or evidences, 



APPENDIX 359 

the sarcinae and yeast tests, are not positive in all cases of 
stasis, and that, therefore, their absence cannot be used to 
rule out stasis. Such exclusion can be done only by exami- 
nation of fasting contents. 

The second use of these supplementary tests, their use 
when a food residue is lacking, is to be employed on the 
chance that by this means we may discover occasionally 
some obscure condition of stasis when the regular test is 
lacking. Such, for example, as local retention of ferments 
in the surface of a neoplasm (Note 1). I have so far in my 
work found two cases by this extra method of applying the 
yeast test to fasting contents, when the food test failed. 
Although these cases are few, the fact is important, and the 
presence of this measure as a routine may result in the occa- 
sional making of an early diagnosis of some such serious 
condition as cancer or ulcer. 

Such is the method for the determination of the existence 
or non-existence of stasis which my study of stomach condi- 
tions has led me to adopt as a routine method in clinical 
work. 

I do not mean to imply that it is the only method of diag- 
nosticating stasis, but simply that it is the best and most 
accurate one, for all cases, which I have found. Stasis may, 
for example, be diagnosticated in some cases by examination 
of the contents obtained at any time, or from the vomitus, 
without recourse to the examination of fasting contents. If 
it is so diagnosticated by the finding, for example, of sar- 
cinae or of food taken on previous days, there is, of course, 
no necessity of further examination. A positive yeast fer- 
mentation test in vomitus or digesting contents has the same 
significance. Cases of stasis are not infrequent, however, in 
which the diagnoses can be determined by the examination 
of the fasting contents only. And the possibility of stasis 
can never be ruled out without such an examination. 

Whether this method can be relied upon in all cases, is a 
matter which can be decided only by practical experience. 



360 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

In my experience, results based upon this method have so 
far proved correct, both as regards positive and negative 
findings, in every instance in which it has been possible to 
verify the evidence of clinical findings by a determination of 
the actual anatomical conditions with which they were asso- 
ciated, — that is, when it has been possible to test the results 
by a scientific method. In support of this statement, I have 
collected in a separate list the records of all my cases exam- 
ined by this method, in which cases, as a result of operation 
or of post mortem, it was possible to determine the actual 
anatomical or pathological conditions present. In such a 
record we have an experimental test of scientific value in 
regard to the value of our clinical findings and of the 
deductions which can be drawn from them in regard to 
diagnosis of the actual conditions present. And by such 
a test the real value of our method of clinical procedure 
is determined. 

A summary of the records of these cases is as follows : 
Among one hundred and eighty cases included in my in- 
vestigation, thirty-nine came to surgical operation or post- 
mortem examination. Of these thirty-nine cases, the test 
cases of our experiment, in twenty-one there had been a 
clinical diagnosis of stasis. In these twenty-one cases of 
" clinical stasis " an " anatomical finding " of obstruction 
of the pylorus — that is, of an actual anatomical cause for 
stasis — was found in every case. 

The actual pathological findings in these twenty-one stasis 
or obstruction cases were : — 

Cancer at the pylorus, ten cases. 

Ulcer at the pylorus, ten cases. 

Adhesions about the pylorus, one case. 

In the eighteen clinical no-stasis cases, the pylorus was 
found to be intact or patent in every case. The actual path- 
ological findings present in these no-stasis cases were : — 

Cancer of the stomach, ten cases. 

Ulcer of the stomach, three cases. 



APPENDIX 361 

Chronic gastritis, two cases. 

No demonstrable lesion of the stomach, three cases. 

That is, in the thirty-nine cases in which it was possible 
to obtain an actual test of the accuracy of our clinical diag- 
nosis of gastrectasis, the clinical diagnosis was confirmed by 
the anatomical finding in every case. 

The testimony of this experimental record is, therefore, 
unanimous in favor of the accuracy of the clinical method 
employed. From it we may deduce three conclusions of 
importance in the clinical study of stomach conditions: — 

1. The existence of stasis in a given case can always be 
diagnosticated by a proper method of investigation. 

2. The clinical sign of a twelve-hour stasis as a constant 
feature of a case is always a sign of a serious condition 
(Note 5, page 362). 

3. Stasis is not, as a rule, an associate of even the serious 
stomach conditions, cancer or ulcer, unless the lesion is situ- 
ated in the region of the pylorus. 

Chapter II. — The Diagnosis of the Conditions op 
Cancer and Ulcer of the Stomach 

The diagnosis of cancer and ulcer of the stomach, if we 
are to consider all cases, the early and the late, is far from 
being on the absolute and simple basis that could be desired 
or that is present in the consideration of insufficient drain- 
age. In some cases, — ulcer with acute hemorrhage, or car- 
cinoma with a palpable tumor, — the diagnosis is simple. On 
the other hand, in many cases of both ulcer and cancer, espe- 
cially in early stages, accurate diagnosis is difficult. 

A careful and long-continued study of these conditions 
has convinced me that it is possible, by a combination of a 
careful study of symptoms and the record of the findings 
obtained by the application of objective methods of diag- 
nosis, to arrive at a probable, if not an absolute, diagnosis of 
either of these two conditions in a high per cent of the cases 



362 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

in which they exist, a much higher per cent than is generally 
recognized. 

The objective findings determined by the use of the 
special methods of stomach examination which experience 
has demonstrated to be useful in connection with the special 
diagnosis of ulcer or cancer of the stomach are : — 

(1) The finding of chronic stasis in the stomach. 

(2) The finding of evidence of bleeding in the stomach. 

(3) The finding or the failing to find free hydrochloric 
acid, or lactic acid, in the stomach contents. 

(4) The finding of abnormal elements in the sediment, — 
fragments of cancer, pus, or numerous or special forms of 
low organisms, as sarcinse, bacteria, or yeast fungi. 

(5) The finding of the size and location of the stomach, 
ascertained by inflation of the organ. 

The importance of stasis as a sign of ulcer or cancer lies 
in the fact that, since the commonest cause of insufficient 
drainage is obstruction of the pylorus from ulcer or cancer, 
the presence of stasis is always one suggestion of the pres- 
ence of ulcer or cancer in the case. 6 The stasis may be due 
to such other chronic affections as atonic dilatation, ptosis, 
or obstructions from the adhesions, hence its existence is 
not pathognomonic of the lesions in question. But the 
more we study the pathology of chronic stasis, the more 
frequently do we find an old cicatrix or a neoplasm, so that 
we are coming to recognize the rarity of simple dilatation as 
a cause of stasis, — that is, of twelve-hour stasis. 

How frequently ulcer or cancer at the pylorus may be the 
cause of stasis in a series of cases can be judged from my 
own records. In my list there are twenty-one cases of 
stasis which came to operation or to post mortem. The 
cause of the stasis was found to be ulcer at the pylorus in 
ten, cancer at the pylorus in ten, and adhesions about the 

6 It is understood that I am speaking here of chronic stasis. Tempo- 
rary conditions of stasis, such as occur in acute affections, in acute gas- 
tritis, or acute spastic stenosis, are to be excluded. 



APPENDIX 363 

pylorus in one. Diagnoses were made in all these cases by 
the method of examination of the fasting contents which I 
have described. That is to say, all were cases of twelve- 
hour stasis. 

This frequency of ulcer or cancer as a cause of stasis is 
probably exceptional. There happened to be no cases of 
simple atonic dilatation in this series. Yet my records 
represent a set of unselected cases, operation having 
been advised in all instances in the clinic where chronic 
stasis was found, excepting, of course, cases of inoperable 
cancer. 

From such results we are justified in saying that the find- 
ing of stasis in any case of stomach disorder is in itself sug- 
gestive of the presence of ulcer or cancer at the pylorus. 
When this sign — stasis — is taken in connection with other 
findings, such as the abnormal size and location of the stom- 
ach, blood in the stomach, an anaemic condition of the patient, 
etc., it frequently confirms the diagnosis of cancer or ulcer. 
Also the finding of stasis which has a food residue as its sign, 
in connection with cancer or ulcer, indicates that the pylorus 
is the seat of the lesion. 

The absence of stasis has no bearing on the question of 
the existence of ulcer or cancer in the stomach except that 
its absence is an argument against the presence of either of 
these lesions at the pylorus. 

According to my experience cancer or ulcer elsewhere 
than at or near the pylorus apparently has no influence 
of a permanent character on the general motor capacity of 
the stomach, or at all events no such influence as would 
cause retention of food for twelve hours. 6 Thus among the 
eighteen cases of stomach disorder showing no-stasis in my 

6 That a neoplasm situated elsewhere than at the pylorus may cause a 
local retention of ferment organisms, as bacteria and yeast, and thus give 
a sign of insufficient drainage in a lactic acid or yeast test, without any 
general affection of motor function as evidenced by a food residue, is 
proven by the observations of Strauss (see p. 353, Xote 1). 



364 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

series which came to operation, there were three cases of 
ulcer and ten cases of cancer. 

The second objective finding which is of special value in 
connection with the diagnosis of cancer or ulcer is the find- 
ing of bleeding in the stomach. Bleeding in the stomach 
may occur, according to the results of research upon the 
subject at present in our possession, as an associate of the 
following gastric diseases, tabulated in the order of its fre- 
quency: cancer, stenosing gastritis from any causes, ulcer, 
acute gastritis from certain irritants, among them alcohol 
(Ewald), acute spastic pyloric stenosis, polyposus ventriculi 
(Clemm), gastric erosion (Einhorn). (See small type, p. 368.) 
Bleeding does not occur in chronic gastritis of either 
the hypoacid or hyperacid type, in nervous affections, 
hyperchlorhydria, or simple hypersecretion, or in simple 
ectasia. (See small type, p. 369.) Of the conditions in which 
bleeding may be found, the last two, polyposus and erosion, 
are very rare, — too rare to count statistically in a differen- 
tial diagnosis based on the blood finding alone. For purposes 
of differential diagnosis we have, therefore, to consider, in 
any case of stomach disorder when bleeding in the stomach 
is proven, either (1) some acute affection, or (2) one of 
three chronic affections. Acute affections can be ruled 
in or ruled out by proper study of the case. If an acute 
condition is absent, the bleeding indicates one of the 
three chronic conditions, — cancer, or ulcer, or stenosing 
gastritis. 

From this summary of our knowledge on the subject it 
appears that the finding of bleeding in the stomach, in the 
course of the clinical examination, if we are dealing with a 
chronic condition, indicates the existence of a serious stom- 
ach affection, either cancer or ulcer, or stenosis of the 
pylorus from some cause (stenosing gastritis). And since, 
as I have already shown, the third condition, stenosis, 
with its secondary gastritis, is in the great majority of 
cases due to cancer or ulcer, the blood finding in the great 



APPENDIX 365 

majority of cases means one of these two affections, cancer 
or ulcer. 7 

This is the clinical significance of a blood finding in either 
the gastric contents or the faeces, which is proven, by the use 
of a proper method of research, to have as its cause a disease 
of the stomach. 

The methods of determining the existence of bleeding in 
the stomach are two in number : (1) the examination of the 
stomach contents, (2) the examination of the faeces. 

Blood may appear in the fasting contents either as fresh 
blood or clots, recognizable to the eye, or as a dark sediment 
of changed blood (coffee grounds), or it may be so thoroughly 
mixed with the contents as to give them no color or ab- 
normal character, the so-called "occult bleeding." 8 

The presence of fresh blood is determined by inspection. 

The presence of changed blood (coffee grounds) or of 
blood in solution ("occult bleeding") is determined by 
the chemical test. 

The best blood test for practical work is the guaiac test 
of Van Deen, modified by Weber. 9 It is performed as 
follows : — 

Five to ten cubic centimetres of the stomach contents are 
acidified with one-third their quantity of glacial acetic acid 
and the mixture is shaken with 5 c.c. of ether. One to 2 c.c. 
of the ether extract is then drained off and added to an 
equal quantity of a freshly made alcoholic solution of gum 
guaiac. To this mixture a little hydrogen peroxide, or 
twenty drops of old oil of turpentine, are added, and if blood 
be present, a deep blue color soon appears. The guaiac 
solution should be made from the yellow parts of the gum, 

7 Boas states that blood is present in the faeces in practically all cases 
of stenosis with secondary gastritis. In the stomach contents no such 
constancy is found. Thus my records show four cases of stenosis from 
cancer and four from ulcer cicatrix, which gave no blood finding. 

8 Boas, Deutsch. Med. WocJi., 1901, No. 20, S. 315. 

9 Weber, Bert. klin. Woch., 1893, No. 19. 



366 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

and should be tested with the peroxide before using. 10 The 
addition of water and chloroform after the above procedure 
increases the delicacy of the test. 

Before concluding that blood in stomach contents is evi- 
dence of bleeding from stomach disease, we must first, by a 
proper method, exclude (1) all outside sources of bleeding, 
as the mouth, or throat, or lungs ; u (2) bleeding from the 
mouth, or oesophagus, or stomach, from irritation by the 
tube ; a (3) the presence of blood-containing substances, 
as uncooked meat ; 13 (4) the presence of certain general 
diseases which may cause bleeding into the stomach, such 
diseases as cirrhoses of the liver, purpuric diseases, pernicious 
anaemia, gall-stones, jaundice, and tubercular peritonitis in 
infants. If we can exclude these possible sources for blood, 
as well as acute stomach affections, a blood finding in the 
fasting or digestion contents, as obtained by tube, means, in 
the great majority of cases, cancer or ulcer. When stasis is 
absent in such a condition, we must conclude that, barring 
the very rare chronic conditions cited, cancer or ulcer is 
present, — for stenosing gastritis, the third possibility, is 
always associated with stasis. 

In the investigation of this subject, I have, during the last 

10 The criticism of the original guaiac test, that it reacted to sub- 
stances other than blood, does not apply to this modified test, as the 
ether does not take np these substances. After all, no better evidence of 
its accuracy is needed than that offered by my experience of its routine 
use in stomach cases, with negative results in all save those of cancer 
and ulcer. 

11 Joachim found no blood test in the faeces of cases of phthisis or 
pneumonia. Such cases might, however, give a chemical blood finding 
in the gastric contents. (Joachim, 15 &.) 

12 Blood caused by the passage of the tube is fresh blood, and, as a 
rule, appears in part floating in mucus or saliva. The use of a very 
soft stomach tube, with a closed, rounded end, will lessen the chance of 
artificial production of blood. 

18 Joachim (loc. cit.) found that cooked meat, ingested by mouth, gave 
no blood test in the faeces. Uncooked meat gave a positive test. (See 
also Hartmann, Note 15 d.) 



APPENDIX 367 

six months, made a routine examination of the blood in the 
fasting contents of all stomach cases which have come under 
my care. All together, one hundred and sixty cases of vari- 
ous forms of stomach disorder were examined. The tests 
used were, first, inspection for fresh blood, and second, the 
guaiac test. The results of this blood investigation are as 
follows : — 

Excluding all cases in which blood might be thought due 
to irritation of the tube (that is, all cases in which small 
amounts of fresh blood were found after the use of the tube, 
and yet examination of f seces at other times showed no blood, 
and all conditions of acute stomach disorder), a blood find- 
ing was present in twenty -two cases. All of these twenty- 
two cases, save one, have come to operation or post-mortem 
examination. The pathological findings in them were : 
cancer of the stomach in fifteen, ulcer in six. One case 
diagnosticated as cancer was not operated upon and was lost 
to sight. That is, omitting the one case which was not 
proven, in an examination of one hundred and sixty cases of 
stomach disorder, a positive, or, more properly speaking, a 
significant, blood finding was present in none of the chronic 
cases, excepting those which were later proven by patho- 
logical examination to be conditions of cancer or ulcer of 
the stomach. 

Such a record is significant in connection with the ques- 
tion of the importance of the blood finding in the stomach 
contents as an aid to diagnosis. The list of cases with 
negative blood findings by clinical diagnosis includes chronic 
gastritis, nervous affections, hyperchlorhydria, hypersecre- 
tion. 

Cases with a negative finding, in which a pathological 
diagnosis was obtained, were : cancer, five cases ; ulcer, five 
cases ; obstruction from adhesions, one case ; chronic gastri- 
tis, two cases ; neurosis, two cases. 

Of eighteen cases of stenosis from all causes, blood was 
found in nine. 



368 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Search for blood in the faeces is conducted in the following 
manner : — 

A portion of f aeces is mixed with water — acetic acid is 
then added and the mixture shaken with ether ; emulsion 
should be overcome by the addition of alcohol. The ether 
extract is then added to a freshly made solution of the guaiac- 
in-alcohol and peroxide of hydrogen or old oil of turpentine. 14 

According to extensive observation with this method of 
research blood tests are not found in the faeces save in some 
special disease of the alimentary tract or of the organs enter- 
ing it. The test is negative in the ordinary conditions of 
diarrhoea (Joachim, Schloss, loc. cif). Its positive value is 
attested by the fact that three grammes of blood introduced 
into the mouth may be removed by this test in the faeces 
(Joachim). 

This method of examining the stools for evidence of bleed- 
ing in the stomach has the difficulty that all other sources of 
bleeding in the course of the alimentary tract have to be con- 
sidered and excluded before a diagnosis of stomach bleeding 
can be made positively. The method is, therefore, inferior 
to the examination of the stomach contents. Negatively, 
however, it is of greater value. In spite of the chances for 
error, the method is of value in connection with the study 
of cases of stomach disease. 

This value may be summarized as follows : — 

1. A positive rinding by the method may offer evidence 
or additional evidence of the existence of cancer or ulcer of 
the stomach. 

2. A negative finding on several repetitions offers evi- 
dence against the existence of cancer (vide small type 
below). 

The subject of the occurrence of bleeding in various forms of 
stomach disorder has been carefully investigated by numerous 
observers, both by the examination of the gastric contents and of 

14 For special modifications and precautions in connection with this 
test, vide Clemm, note 15 c. 



APPENDIX 369 

the faeces. The mass of the results on which our knowledge is 
based was obtained by study of the faeces. 15 

According to these results bleeding is practically a constant 
associate of the following stomach diseases : cancer, stenosing 
gastritis, polyposis ventriculi. Einhorn {Journal American Medi- 
cal Association, May 2, 1899) records cases of a condition known 
as gastric erosion in which a blood finding in the stomach con- 
tents is a feature. This condition must, therefore, be added to 
the above list. Boas found blood in repeated examinations in 
the faeces of sixty-five out of sixty-seven cases of cancer of the 
stomach. 15a Joachim found blood in twenty out of twenty-one 
cases. 15 b 

Blood is common but intermittent in appearance in ulcer. 
Joachim found it at times in the faeces in twenty-three out of 
twenty-eight cases of ulcer. It may occur in acute gastritis 
from alcohol (Ewald) , or from other causes, and from acute consec- 
utive spastic pyloric stenosis. It is never found in nervous affec- 
tions or simple ectasis. It is very rarely, if ever, found in chronic 
gastritis, according to extended observations of Boas, Schloss, 
Joachim, Clemm (loc. cit.). Kuttner's opinion that blood does 
occur in this affection (Kuttner, Zeit. fur klin. Med., Bd. 45) 
appears to be overruled by weight of testimony. 

The study of the acids of stomach contents has value in 
connection with the diagnosis of cancer and ulcer. 

The chief points of this acid analysis which may have 
importance in this connection are (1) the presence and quan- 
tity of free hydrochloric acid, and (2) the presence of lactic 
acid. 

It has long been recognized that a diminution in the secre- 

15 a. Boas, "Uber occulte Magen Blutengen," Deutsch. med. Wochen- 
schrift, No. 20, 1901. " Uber d. Diagnosis d. Ulcus Ventriculi," Deutsch. 
Med. Woch., No. 47, 1903. " Beitr'age zur Kenntniss der Magen carcinoma 
Bluten," Archiv. f. Verdauungs-Krankheiten, Bd. vii, 3413. Kochman, 
Archiv.f. Verdauungs-Krankheiten, Bd. viii, S. 545. 

b. Joachim, Berl. klin. Woch., 1904, xii, S. 466. Schloss, Archiv. f 
Verdauungs-Krankheiten, Bd. x, H. 3, S. 257. 

c. Clemm, Archiv.f. Verdauungs-Krankheiten, Bd. x, H. 4, S. 373. 

d. Hartmann, Archiv. f. Verdauungs-Krankheiten, Bd. x, No. 1, S. 48. 
Sclimiliusky. Munchen med. Woch., 1903, No. 49. 



370 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

tion of the hydrochloric acid of the gastric juice is a common 
associate of cancer of the stomach. And although excep- 
tions to this rule are not uncommon, it may definitely be 
stated that such a diminution, when determined by an ab- 
sence of free HC1 in the digestive contents obtained one hour 
after an Ewald test meal, 16 is the rule in cases of cancer 
of the stomach, as we see them in practice ; that is, at the 
late stage of development when diagnosis of cancer is com- 
monly made. So an absence of free HC1 has a certain 
importance in connection with the diagnosis of cancer. 
This importance, however, is limited, owing to two facts : 
first, an absence of free HC1 is sometimes an associate of 
conditions other than cancer ; 17 second, it is not uncommon 
to find free HC1 in well-developed cases of cancer (see Cases 
No. IV, XXXVII, in my table). In fact, absence of free 
HC1 is probably only a late symptom of cancer in a great 
majority of cases. 

These points are well illustrated in my records. Of one 
hundred and sixty cases, free HC1 was absent, both in the 
fasting contents and after the test meal, in nineteen. Of 
these, fifteen were cases of cancer, all seen at operation or 
post mortem. The others were not operated upon. 

16 The question of the presence or absence or of the quantity of free 
HC1 is best determined in a contents obtained after a test meal, for 
example a contents expressed one hour after an Ewald breakfast. Ab- 
sence of free HC1 in a fasting contents may occur in normal individuals 
(see records in " The Diagnosis of Gastrectasis," Boston Medical and 
Surgical Journal), or in conditions of disease when a plentiful supply 
is present under the stimulation of food (see Cases III, VIII, XXIV, 
XXXIV, in table) . The presence of free HC1 in a fasting contents is suffi- 
cient evidence of the presence of a secretion and obviates the necessity of 
the test-meal estimate, save to estimate relative insufficiency (Gluyinski). 

17 In a research made in 1899 upon stomach disorders I found the 
absence of free HC1 a characteristic of twenty-four cases, none of which 
at the time showed any special evidence of cancer. I have records of 
sixteen of these cases up to date, and no one of these has developed any 
further evidence of cancer in the interval. Boston Medical and Surgical 
Journal, May 17, 1900, 



APPENDIX 371 

Among twenty cases of cancer (pathological diagnosis) 
free HC1 was absent in fifteen, both in the fasting and 
digesting contents ; HC1 was present in the contents (test- 
meal contents) in five. Of these five cases, four were located 
at the pylorus and one was on the lower wall of the stomach 
(an early case without metastasis) ; two of these cancers 
of the pylorus were developed upon former ulcer cicatrices ; 
three of the HC1 cases were advanced, and showed 
metastases. 

It appears from this summary that some, but a very lim- 
ited, value can be placed on the estimation of free HC1 
as an aid in the diagnosis of cancer. In this connection 
we can say, merely, that, given signs of a serious stomach 
trouble, stasis, or blood, or other symptoms, the absence 
of free HC1, after a test meal, is a point in favor of cancer, 
but that the presence of HC1 by no means rules out that 
condition. 

Ulcer of the stomach, as a rule, is associated with a plenti- 
ful secretion of HC1, — in fact, an excessive secretion, 
hyperchlorhydria, is a common associate of ulcer. Cases 
of ulcer with no free HC1 have been reported (vide Bial, 
Berl. hlin. Woch., 1895, No. 6). They are very rare, how- 
ever. My records show the following findings on this sub- 
ject : — 

Of ten cases of ulcer (pathological diagnosis), free HC1 
was present, both in the fasting and the test-meal contents, 
in all. The quantity of free HC1 (after the Ewaldmeal) 
was normal, below 0.14 per cent, in four; high (over 0.15 
per cent) in six ; excessive (over 0.2 per cent) in four. 

As between ulcer and cancer, therefore, we can say, 
merely : (1) an absence of HC1 favors the latter ; (2) 
presence of HC1 may go with either, though more common 
in ulcer ; (3) excess of HC1 suggests ulcer. 

Lactic acid, when present in the contents of the stomach 
twelve hours after a meal (the so-called fasting contents), is 
an indication of stasis or stagnation. Lactic acid is in such 



372 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

cases, in part at least, the product of abnormal bacterial fer- 
mentation in the stomach, for the development of which 
stasis offers an opportunity. This lactic fermentation does 
not occur in all conditions of stasis, but only in those in 
which the secretion of hydrochloric acid is diminished, — 
cases in which the contents contain no free HC1 or small 
quantities of the acid. 186 

This combination of stasis and diminished HC1 secretion 
is much more common in cancer than in other conditions. 
Therefore lactic acid is more common in association with 
cancer than with other diseases. It may, however, occur 
when stagnation is due to other conditions. 18 c It does not 
occur in cancer unassociated with stasis. 18 " 

These facts in regard to lactic acid are well illustrated by 
my cases. 

In one hundred and sixty cases lactic acid was present in 
the fasting contents in seven. These were all cases of cancer 

186 Lactic acid fermentation does not occur in the presence of an 
acidity of .12% total HC1 (not free HC1). Strauss, Zeit.f. klin. Med., 
Vol. XXVIII. Lactic acid, though the rule in cases of stasis associated 
with diminution of HC1, is for some unexplained reason not always 
present in such cases. Boas, Zeit. f. klin. Med., Vol. XXV, Nos. 3 and 4. 

18 e Lactic acid may be present in conditions other than cancer pro- 
vided that stagnation associated with diminution of HC1 secretion is 
present. Bial, Berl. klin. Woch., 1895, No. 6, reports a case of ulcer at the 
pylorus where HC1 was absent and lactic acid present. Kosenheim, 
Deutsch. Med. Woch., 1895, No. 15, reports similar cases. 

18 a Stagnation of some kind is essential for lactic acid formation 
by fermentation in the stomach. As a rule the presence of the acid in 
the fasting contents means actual motor insufficiency — most commonly 
stenosis from cancer. It may occur, however, where the general motor 
function is preserved but where a stagnation of bacteria is accomplished 
through the harboring of these organisms in the folds or rough surfaces 
of a neoplasm. Strauss, Zeit.f. klin. Med., Vols. XXVI, XXVII, reports 
such cases — all cases of cancer. It does not occur in all cases of cancer, 
however, as demonstrated by my records (vide also Klemperer, Deutsch. 
Med. Woch., 1895, No. 14), but only if the cancer happens to cause stag- 
nation either by stenosis or by its rough surfaces. Lactic acid bacilli 
are always present in the mouth (Miller). 



APPENDIX 373 

at the pylorus, and showed the combination of stasis and 
absence of free HC1. Among twenty cases of cancer, lactic 
acid was absent in thirteen, including three cases of cancer 
at the pylorus, with plentiful secretion of HC1, and ten cases 
of cancer unassociated with stenosis. Lactic acid was absent 
in all cases of stasis in which HC1 was present in the fast- 
ing contents, the cases of stenosis from ulcer or adhesions. 
It was absent in all cases unassociated with free HC1 in 
which stasis was not an associate. 

Lactic acid should be looked for in the fasting contents. 
In contents after a meal it may be present as ingested acid 
or as a production from the lactates of the food, and so be 
without pathological significance. The test for lactic acid, 
to be employed in clinical work, is the modified Ufflenian 
test given on p. 256. 19 

The study of the sediment of the contents or washings 
from the stomach may give valuable information as to the 
diagnosis of ulcer or cancer. 

In some cases fragments of tissue, which when hardened 
and examined in section proved to be cancer, have been 
found. Such a finding is, of course, pathognomonic. 20 

The finding of isolated cells resembling cancer cells may 
be suggestive, but in my experience diagnosis by such find- 
ing is uncertain. I have known several mistaken diagnoses 
which have been made in this way. 

The finding of a sediment of pus alone, in the fasting con- 
tents, is said by some observers to be suggestive of cancer. 21 
I have made this finding in two cases. One proved to be 
cancer. (See Case XIII.) The other was not operated 
upon. 

19 De Jong, Archivf. Verdauungs Krankheiten, Bd. 11, H. 1, S. 59. Rec- 
ords in regard to lactic acid are of doubtful value unless obtained by 
such an accurate method of testing, or by Boas's test. The regular Uffle- 
man test without the addition of HC1 and solution in ether cannot be 
depended upon. 

20 Hemmeter, " Diseases of the Stomach," p. 526. 

21 Strauss, Berl. klin. Woch, 1899, No. 40. 



374 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

A study of the bacteriology or of the lower organisms of 
the sediment often is of value, particularly in connection 
with other findings. As already stated, bacteria are present 
in all stomach contents. In my experience, they are few in 
number in contents containing free HC1, whether the con- 
tents be taken from the fasting stomach or after a meal. In 
cases containing no free HC1 the bacteria may be fairly 
numerous in the fasting contents, even in the normal stom- 
ach, or in conditions where neither stasis nor cancer exists. 
In conditions of stasis where no free HC1 is present, they 
are very numerous, forming a marked contrast to the picture 
found in any condition where no stasis is present, barring 
only the presence of active suppuration in the stomach ; 
and a diagnosis of stasis with diminished hydrochloric acid 
can often be made in a given case by this finding alone. 
As such a combination is more commonly an associate of 
cancer than of any other condition, the finding of numerous 
bacteria in a given case may serve as one suggestion toward 
the diagnosis of cancer. 

Yeast fungi are present in the normal stomach contents. 22 
Their number, however, is small even in the fasting contents, 
and they do not appear as actively budding. In conditions 
of stasis, however, particularly in stasis contents containing 
plenty of free HC1, large numbers of actively budding yeast 
fungi often are present in marked contrast with normal con- 
ditions, or conditions of stasis contents without free HC1 
(vide results of my study of the vital content of one hun- 
dred and eighty fasting contents, in article on " Gastrecta- 
sis," Boston Medical and Surgical Journal, Vol. CLII). 

A diagnosis of stasis with free HC1 often can be made bj 
this finding alone, such a combination being more common 
in cases where the stasis is due to ulcer or simple dilatation, 
than in malignant conditions. 

The finding of sarcinse 4 in numbers in the contents is, as 

22 Strauss, Zeit. f. klin. Med., Vol. XXVIT, p. 70. 
4 Oppler, Munchen Med. Woch., 1894, No. 29. 



APPENDIX 375 

already stated, a sign of stasis, and as such is useful in con- 
nection with the further diagnosis of cancer or ulcer. As a 
rule, this organism, going with stasis with a plentiful supply 
of HC1, is associated with conditions of so-called benign 
stenosis, ulcer, or simple dilatation, as contrasted with cancer. 
I have found them, however, as well as free HC1 in cancer 
stenosis. (See Cases IV, XXXVII.) 

The finding of the large bacillus known as the Oppler- 
Boas bacillus in the contents is not, in my experience, dis- 
tinctive. I have found it in several fasting contents in 
which no stasis or cancer existed. When present in large 
numbers, it has the same significance that a finding of large 
numbers of any bacteria has, in that it shows stasis with 
fermentation (vide Oppler, " Zu Kenntniss d. Mageninhalte 
bei Carcinoma Ventriculi," Dewtac^. Med. Wochenschrift, 1895, 
No. 5). 

The study of the size and location of the stomach by the 
special clinical method of inflation of the organ with air has 
an important bearing upon the diagnosis of cancer or ulcer, 
in that we are enabled through it to rule in, or to rule out, 
the existence of dilatation or ptosis of the stomach, in con- 
sidering the differential diagnosis of the case. 

The mere existence of a large stomach or of ptosis has, in 
my experience, no great significance, unless it have associ- 
ated with it evidence that the motor function of the organ is 
disturbed, i.e. the presence of stasis. If stasis is present, 
however, the findings in regard to the size or location of the 
organ at once assume importance; for we then encounter 
the question whether the stasis may be accounted for by 
simple atonic dilatation or by ptosis, or whether its cause 
must be sought in cancer or ulcer, or some other pyloric 
obstruction. If, therefore, we have stasis in a case and an 
absence of dilatation or ptosis, the indications are practically 
absolute in favor of cancer or ulcer at the pylorus, or of the 
rare condition of obstruction from other cause, as adhe- 
sions. If in stasis we find marked dilatation or ptosis, we 



376 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

have to regard these conditions as possible causes of the 
stasis. 23 

If I were to go by my experience alone, as far as it con- 
sists in a study of cases in which the actual abnormality 
present was determined by pathological examination, and 
such cases are the only ones upon which it is justifiable to 
form an opinion, I should conclude that the cause of chronic 
gastrectasis, as determined by the method of investigation 
used in this work, is always an obstruction of the pylorus 
from some cause. For we recall that such a condition was 
present in all my cases of stasis (see p. 360), both of those 
with stomachs of normal size, and those with greatly dilated 
stomachs. That is, my results would lead me to expect the 
existence of an old cicatrix of ulcer in the majority of cases 
of dilatation of the stomach of long standing, which as far as 
clinical evidence goes are often classed as cases of atonic 
dilatation. 

It is, however, an undoubted fact that conditions of 
stasis due to simple dilatation and atony, or due to ptosis 
of the stomach without any obstruction of the pylorus, past or 
present, do exist. And it is quite possible that dilatation 
or ptosis may cause a twelve hours' stasis, such as was pres- 
ent in my cases. So that we must consider this possibility 
in chronic stasis where dilatation or ptosis are associates; 
remembering, however, that stasis from this cause, as com- 
pared with obstruction, is rare. In fact, the results of my 
pathological findings have led me to make the clinical diag- 
nosis of obstruction from ulcer or other causes in the majority 
of cases, even when no clinical evidence of ulcer existed, 
simply on the statistical chances. 

This completes my review of the special methods of clini- 

23 Hypertrophy of the muscular wall of the stomach is common in 
cases of stenosis. We do not therefore in these cases get the same pro- 
portionate dilatation as with atony. Also the propulsive power of the 
stomach is greater in stenosis. Extreme dilatations are not, however, 
uncommon in stenosis. 



APPENDIX 377 

cal examination, and of the findings by these methods, which 
in my experience have proven important aids to the facts of 
the history and regular physical examination, in the consid- 
eration of the diagnosis of cancer or ulcer of the stomach. 

Chapter III. — Record of Investigation by the 
Clinical Methods given in this Review of Thirty- 
seven Cases of Stomach Disorder which came to 
Operation or Post-mortem Examination 

In this review, so far, I have given an outline of the useful 
methods of clinical examination specially designed for the 
study of disorders of the stomach, and of the value of the 
several findings obtained by the use of these methods, in 
connection with the diagnosis of that class of chronic stom- 
ach disorders which are or may be amenable to surgical 
treatment. The real value of the findings and of the meth- 
ods appears, however, not so much in the statistical record 
of the individual findings, since few of them are absolutely 
diagnostic of or constant in any one particular condition, as 
in the aid to diagnosis which they provide when the evidence 
of all together is considered in connection with any particular 
case. I wish to offer such a demonstration by reporting the 
records of a series of my cases of stomach disease which 
have come to operation or post-mortem examination. This 
series, in providing the actual pathological finding in each 
case, offers a set of scientific experiments in regard to the 
indications of the various clinical findings or combinations 
of findings and to the actual capacity of clinical diagnosis 
of stomach disorders, which can be obtained by thorough 
investigation of the cases, along the lines indicated in this 
review. And I present their records, both as a collection 
of data on the subjects of cancer and ulcer of the stomach, 
and as a demonstration of the use and usefulness of these 
special methods, and of a thorough method of investigation 
as a routine practice in clinical work. 



378 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

As a preface to the report, I will summarize the method 
of clinical procedure used in the collection of the findings, 
and the methods of reasoning employed in deducing the 
clinical diagnosis from these findings in the individual 
cases. 

Each stomach patient who presented himself at the 
clinic was put through the following routine, eliminating, 
of course, conditions of acute hemorrhage : — 

The first point investigated in each patient was, whether 
or not his case showed evidences of the existence of any of 
the pathological conditions for the relief or cure of which 
surgery is a therapeutic method; namely, one of the two 
diseases, cancer or ulcer of the stomach, or gastrectasis or 
insufficient drainage, from any cause, such as would justify 
an absolute or probable diagnosis of any of these con- 
ditions. 

If evidence of such conditions was found, and the case 
appeared one which demanded or was likely to benefit 
from operation, operation was prescribed. If definite evi- 
dence of the existence of any such conditions were lack- 
ing, the case was further investigated by the measures of 
the internist. 

The study of each case was conducted as follows : — 

After the record of the history of the case and of the 
physical examination had been made, one of two courses 
was adopted, depending upon the circumstances. 

1. If the record suggested strongly the presence of stasis, 
or if a tumor was present, or if the patient came from a dis- 
tance, the contents of the stomach were obtained by the tube 
at once, — regardless of the time elapsed since a meal. By 
this means it was often possible, through the finding of 
evidence of stasis, such evidence as sarcinse, or food rem- 
nants clearly those of food taken on a previous day, or posi- 
tive yeast fermentation, or through the finding of blood 
(excluding meat), to expedite diagnosis without the delay 
incident upon obtaining the fasting contents. Thus I could 



APPENDIX 379 

place the case immediately in the hospital wards, where an 
analysis of the fasting contents was made at a later date 
for purposes of confirmation or record. 

2. If such immediate action was not indicated, or if the 
results of the above methods did not give positive indica- 
tions of a definite surgical lesion, the patient was instructed 
to eat regular meals, excluding all meat and blood-contain- 
ing substance from the diet, for forty-eight hours, and then 
to return, after a twelve hours' fast. Then the contents of 
the fasting stomach were obtained by the tube. 

After the expression of contents, the stomach was inflated 
with air, and its size and location and the presence of a 
tumor investigated. 

The contents of the fasting stomach were examined with 
reference to the following characteristics : — 

(<z) The presence of an abnormal food residue, recogniz- 
able by macroscopic examination or by study with the 
microscope. 

(b) The presence of sarcinae in the sediment. 

(<?) The presence of lactic acid. 

(d) The presence or absence of free hydrochloric acid. 

(e) The presence of blood (inspection, or guaiac test). 
(/) The sediment was also examined in regard to the 

number of low organisms, the presence of pus, and of 
fragments of cellular growths. 

(#) After the above examinations the contents were sub- 
jected to the yeast fermentation test. (This test is necessary 
only when other evidences of stasis are lacking.) 

After the expression and examination of the fasting con- 
tents, the patient was given an Ewald test meal, when the 
contents were expressed and examined qualitatively and 
quantitatively for free HC1. This step is necessary only 
in cases in which diagnosis has not already been determined 
by the previous examinations, or when no free HC1 is present 
in the fasting contents. Its chief use is for discrimination 
in regard to the presence or absence of free HC1 and the 



380 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

estimation of the quantity, — points which cannot be deter- 
mined by the examination of the fasting contents. (See 
Cases III and XXIV.) (Tabora, Deutsch. Med. Woch., 
1905, p. 576.) 

The clinical procedures should be carried out to the point 
of diagnosis, or, failing a final diagnosis to their limit, in 
every case which comes to the clinic. If, finally, stasis is 
excluded, and the question of cancer or ulcer is left not 
proven, further investigation as to the character of the dis- 
order present may be carried on under medical observation, 
whether for a hyper-secretion, an atrophy of the stomach, 
or nervous dyspepsia. 

The general method of reasoning employed in arriving at 
a clinical diagnosis from the physical findings, particularly 
those findings discovered by the use of these special methods, 
was the following : — 

1. The presence of stasis, as evidenced by food residue in 
the fasting contents, or of sarcinse in any contents, was taken 
to indicate the existence of obstruction of the pylorus from 
cancer or ulcer or adhesions, or other cause, or possibly the 
existence of simple atonic dilatation or ptosis without actual 
obstruction. 

2. The presence of stasis or stagnation as evidenced by 
the presence of lactic acid or yeast fermentation in the fast- 
ing contents, no food residue being present, was taken to indi- 
cate one of the above causes of stasis, obstruction of the 
pylorus or atony, or as an alternative a neoplasm situated 
anywhere on the stomach wall. (See Note 18.) 

In differentiating these various conditions which may exist 
as underlying causes of stasis, the following observations 
were of value: — 

The absence of ptosis or of marked dilatation, shown by 
the inflation test, tended to rule out atonic dilatation as the 
cause of stasis, and to fix the diagnosis as ulcer or cancer or 
adhesions at the pylorus. (See Cases II, XII.) The pres- 
ence of marked ptosis or dilatation gave these simple causes 



APPENDIX 381 

— such as atonic dilatation — consideration as possible causes 
of the stasis, though, as a rule, even when marked dilatation 
was present, a diagnosis of ulcer or cancer as its cause was 
made, from the combined symptom picture. (See Cases 
XV, XIX.) 

Blood, in addition to stasis, made very definite the indica- 
tion of cancer or ulcer as the cause of the stasis. The ab- 
sence of free HC1, after a test meal, or the presence of lactic 
acid, in combination with stasis, were strongly suggestive of 
cancer as the cause of the stasis, as against ulcer or other 
cause. (See Cases V, XII, contrasted with Cases II, IX.) 
The presence of free HC1 with stasis, though more common 
with ulcer than with cancer, is so common in cancer that it 
was given but secondary weight in differential diagnosis. 
(See Cases IV, V, XXXVII.) 

If stasis was not demonstrable in a case, obstruction of 
the pylorus or dilatation or ptosis of sufficient degree func- 
tionally to cause insufficient drainage were ruled out ; and 
the diagnosis was reduced to a question of ulcer or cancer, 
located elsewhere than in the pylorus, or to some one of the 
affections of the stomach not necessitating surgical inter- 
ference, — that is, to some one of the various " medical " 
affections of the organ. 

As to the special diagnosis of cancer or ulcer, under these 
latter conditions, the following findings were regarded as 
significant : — 

1. The presence of blood in the stomach contents — 
fresh blood or blood found by a chemical test (outside 
causes of this phenomenon and an acute condition being 
excluded) — was taken as strongly suggesting the existence 
of cancer or ulcer. (See Cases I, III, XVI.) 

2. With the finding of any symptom suggesting cancer 
or ulcer, the absence of free HC1, both in the fasting 
contents and after the Ewald meal, was taken to favor 
cancer; while the presence of free HC1, especially of 
an excessive quantity of free HC1, was regarded (here 



382 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

where no stasis was present) as favoring ulcer (vide 
page 371). 

In the absence of any of the above significant findings 
or combinations of findings, the diagnosis of cancer or ulcer, 
or other affection of the stomach demanding surgical inter- 
ference, was thought to be not proven, barring, of course, 
cases with a history of hsematemesis, or with a showing 
of stomach symptoms associated with cachexia. 

In my investigation one hundred and sixty cases of 
stomach disorder were examined by the above method. 
The records of those of the cases in which a pathological 
examination was obtained, thirty-seven in number, are given 
in the chart. In this chart I give, as of direct value in 
diagnosis, in the record in each case, first, the clinical find- 
ings obtained by the use of the special methods of physical 
examination reviewed, — such as the presence of food residue, 
blood, the presence of dilatation by inflation ; also certain 
facts of the history, as age, or duration of symptoms, or of 
the regular physical examination, as the presence of tumor 
or cachexia. Then I give the clinical diagnosis as deduced 
from these findings, and finally I report "the anatomical or 
pathological examination, at operation or post mortem. 

A summary of these records is as follows : — 

Total number of cases of stomach disorder investigated, 
one hundred and sixty. 

Number in which anatomical or pathological diagnosis was 
obtained, thirty-seven. 

In these thirty-seven cases the corresponding records of 
the clinical diagnosis made previous to operation and of the 
anatomical or pathological diagnosis made at operation or 
post mortem are as follows : — 

Eighteen cases, clinical diagnosis, cancer; pathological 
diagnosis, cancer in all. 

Twelve cases, clinical diagnosis, ulcer ; pathological diag- 
nosis, ulcer in eleven cases, cancer in one case. 

One case, clinical diagnosis, gastrectasis ; probable cause, 



APPENDIX 383 

cancer or ulcer. In this case the pathological diagnosis was 
adhesions about pylorus from gall-bladder. 

One case, cause of symptoms unknown. Stomach con- 
tents normal. In this case the pathological findings were, 
chronic appendicitis, and large mesenteric glands. Stomach, 
no lesion. 

Three cases, diagnosis, neurosis ; no cause for operation. 
Pathological finding in all, no lesion of stomach. 

One case of hypoacidity ; operated upon for ventral hernia 
and explored for possible cancer. Contents normal save for 
hypoacidity. Pathological finding, stomach intact. 

That is to say, in thirty-one cases of stomach disorder in 
which the clinical findings pointed to the existence of cancer 
or ulcer of the stomach, and in which such a diagnosis was 
definitely made from the clinical findings, one of the two 
was found in all, and the diagnosis of the type of lesion was 
correct in all save one case. In three cases in which no cause 
for operation was found clinically, no cause was found at the 
operation. In two cases in which the clinical findings failed 
to show definite evidences of an organic lesion, but which 
were operated upon for other reasons, no lesions of the 
stomach were found. 

The accuracy of the evidence gained by these clinical 
methods of examination is still more marked if we study 
the testimony of the records in regard to ascertaining the 
location of the diseased conditions. These records show : — 

Nine cases clinical diagnosis of cancer at the pylorus ; the 
pathological finding in these nine cases, cancer at the 
pylorus in all. 

Nine cases clinical diagnosis of ulcer involving or occlud- 
ing pylorus ; the pathological diagnosis in these cases : ulcer 
at pylorus, eight cases ; cancer at pylorus, one case. 

The conclusion that can be drawn from work, in regard to 
the accuracy of diagnosis which can be achieved through the 
practice of a thorough method of clinical examination in all 
cases of stomach disorder, is certainly a definite one, 



384 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 



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390 SURGICAL ASPECTS OF DIGESTIVE DISORDERS 

Although the number of observations in this series is 
limited, the record is so emphatic that it encourages us to 
believe that if such a method of study is applied as a routine 
in all stomach cases, much more accurate results as regards 
diagnosis will be obtained than at present are the rule. As 
a result, we shall on the one hand bring to operation at 
an earlier date than at present those causes in which opera- 
tion is serviceable, and on the other hand we shall have 
fewer cases operated upon unnecessarily, or upon insufficient 
evidence. 

I have in this report omitted the histories and symptoms 
of the cases, for the reason that the investigation was de- 
signed to determine not the full roster of the signs and 
symptoms of cancer and ulcer, but simply the value of the 
findings by special or expert methods of stomach investi- 
gation. 

The value of obtaining facts by these special methods, in 
addition to those of the history and physical examination, is 
demonstrated in a general way by the great accuracy of these 
records of diagnosis. Of course we cannot say what the 
results in the same cases would have been had the special 
findings not been at hand, and had the history and physical 
examination been the only data for diagnosis. It is safe to 
say, however, that our conclusions would have been less cor- 
rect, and that, in many instances, guesswork would have 
replaced scientific deduction. 



INDEX 



Acid, acetic, 51. 
Acid, fatty, 51. 
Adhesions, 64, 160. 
Adhesions, perigastric, 124. 
Ampulla, 271. 
Ampulla of Vater, 231. 
Andral, 62. 
Andrews, 201. 
Aneurism, 55. 
Appendicitis, acute, 326. 
Appendicitis, chronic, 332. 
Appendix region, 39. 
Appendix stump, 345. 
Appendix vermiformis, 320. 
Aristotle, 3. 
Arnott, 64. 
Aselli, G., 12. 
Atonic conditions, 80. 
Auscultation, 42. 

Barry, E., 14. 

Beaumont, W., 29. 

Bellini, Laurentio, 9. 

Bernard, C, 31, 109. 

Bertignon, 263. 

Bevan, A., 152, 186, 198, 201, 244. 

Beyea, 306. 

Bichat, 21. 

Bile passages, 226. 

Bile passages, surgery of the, 249. 

Bilious, 237. 

Billings, 230. 

Billroth, 200. 

Billroth's first method, 208. 

Billroth's second method, 208. 

Blake, J. B., 198. 

Bleeding in jaundiced patients, 262. 

Blood, examination of the, 55. 

Blood vomited, 52, 118. 

Blumenbach, 18. 

Boas, 67. 

Bockel, 291. 

Boerhaave, 15, 27. 

Borelli, 6. 

Brown, 23. 



Bruns, 181. 
Biingner, von, 230. 
Burne, John, 325. 

Cabot, A. T., 313. 

Cabot, R. C, 246. 

Cadwalader, Thomas, 325. 

Cammidge, P. J., 287. 

Cancer, 64. 

Cancer of the bile passages, 243. 

Cancer of the gall-bladder, secondary, 
244. 

Cancer of the stomach, 124, 198. 

Cancer of the stomach, diagnosis, 
202. 

Cannon, W. B., 198. 

Carle, 142. 

Carlsbad, 238. 

ChapmaD, N., 24. 

Chaput, 183. 

Chloride, calcium, 263. 

Cholangitis, 229, 230, 243, 271. 

Cholecystectomies, 252. 

Cholecystectomy, 250, 254, 266, 268. 

Cholecystectomy, indications for, 257. 

Cholecystectomy without drainage, 
274. 

Cholecystendysis, 259. 

Cholecystenterostomy, 260, 273. 

Cholecystostomies, 252. 

Cholecystostomy, 250, 255, 265. 

Choledochenterostomy, 261, 273. 

Choledocholithotomy, 259. 

Choledochotomy, 259, 269. 

Cholelithiasis, 226. 

Cholelithiasis complicated with can- 
cer, 245. 

Chopart, 250. 

Cirrhosis, 64. 

Cirrhosis, gastric, 164. 

Coffee grounds, 52. 

Complication, 196. 

Conclusions of Greenough and Joslin, 
137. 

Connor, 200. 
391 



392 



INDEX 



Cooper, C. M., 272. 
Courvoisier, 200. 
Courvoisier's law, 246. 
Crises, Dietl's, 310. 
Cruveilhier, 105. 
Cullen, 23. 
Cuneo, 205. 

Cunningham, J. H., Jr., 164. 
Cushing, 215. 
Czerny, 181, 201, 223. 

Death, causes of, 196. 

Deaver, J. B., 320, 327, 331. 

De Reaumur, 17. 

Desault, 250. 

Diarrhoea, persistent, 53. 

Dieulafoy, 105. 

Digestion, symptoms of faulty, 236. 

Dilatation, male and female types of, 

82. 
Dilatation associated with simple 

hypertrophy, 70. 
Dilatation of the stomach, symptoms 

and signs, 72, 82. 
Dilating the large intestine, 44. 
Dobbs, 250. 
Doyen, 169. 
Drainage, hepatic, 270. 
Drainage operation, 151. 
Duchainois, 250. 
Duct of Wirsung, 231. 
Duodenum, 40. 
Dupuytren, 324. 
Dyspepsia, 113. 
Dyspepsia, chronic, 141. 

Edebohls, G. M., 323. 
Enemata, nutrient, 131, 133. 
Erosions of Dieulafoy, 105, 162. 
Ewald, C. A., 64, 227, 319. 
Ewald test breakfast, 46. 

Fantino, 142. 
Eat necrosis, 278. 
Eenger, 246, 322. 
Fermentation experiments, 51. 
Finney, J. M. T., 151, 201. 
Finney's gastro-pyloro-duodenosto- 

my, 69, 159, 165, 167, 187, 273. 
Fitz, R. H„ 198, 276, 293, 323, 325, 

333. 
Flint's " Clinical Medicine," 58. 
Forty years ago, 57. 



Fothergill's "Handbook of Treat 
ment," 58. 

Galen, 3, 22. 

Gall-bladder, draining the, 262. 

Gall-bladder, empyema of the, 243. 

Gall-bladder, removing the, 262. 

Gall-bladder, rupture of the, 243. 

Gall-stone formation, 227. 

Gastrectasia, 66. 

Gastrectasis, 67, 148. 

Gastrectomies, 219. 

Gastrectomy, 207, 210. 

Gastrectomy, total, 200, 224. 

Gastric dilatation, 66. 

Gastro-duodenostomy, 187. 

Gastroenterostomy, anterior, 186. 

Gastro-enterostomy for cancer, 220. 

Gastrojejunostomy, 170. 

Gastrojejunostomy, posterior, 170. 

Gastroptosis, 165. 

Gastrostomy, 208. 

Glemard, 62, 298, 319. 

Gle"nard's disease, 298. 

Glisson, Francis, 19. 

Glover, J., 18. 

Glycosuria, 286. 

Glycosuria, alimentary, 286. 

Gmelin, 66. 

Goldbeck, 325. 

Gonococci, 54. 

Granules, iodophilic, 55. 

Greeks, 2. 

Greenough, R. B., 100. 

Gross, 26. 

Guaiac test, 52. 

Gunzburg's reagent, 47. 

Hacker, von, 200. 

Haller, 15, 16. 

Halsted, 269, 318. 

Halsted's hammer, 269. 

Hancock, 324. 

Harrington's segmented ring, 195. 

Hartmann, 142, 143. 

Hawkins, 333. 

HC1, absence of, 48. 

HC1 test, 47. 

Heineke-Mikulicz pyloroplasty, 152. 

187, 192. 
Hemorrhage, 64, 85, 128, 147, 154. 
Hemorrhage from chronic ulcer, 155. 
Hewes, H. F., xii. 



INDEX 



393 



Hippocrates, 22. 

Homans, John, 325. 

Hoppe-Se> icf , 250. 

Horn, van, 12. 

Hunt, 4. 

Hunter, J., 18. 

Hutchinson, Woods, 321, 331. 

Hydrochloric acid, percentage of free 

and combined, 49. 
Hysterical conditions, 56. 

Inflation, 48. 
Inspection, 41, 42. 

Intestinal prolapse, operative treat- 
ment of, 304. 
Intestines, vestibule of the, 139. 
Iodophilic granules, 55. 

Jacquin, 19. 
Jadelot, 323. 

Joslin, E. P., 100, 147, 158. 
Journal, Boston Medical and Surgi- 
cal, 57. 
Journal, British Medical, 57. 

Kader, 208. 

Kaufmann, 70, 232, 240. 

Kautsch, 142. 

Kehr, 240, 254, 270. 

Keith, 308, 309, 312. 

Kelley, H. A., 323. 

Kidney, floating, 70, 307, 314. 

Kocher, 141, 201, 209, 223, 250. 

Kronlein, 198, 201, 222. 

Kuhn, 271. 

Kussmaul, 163. 

Laboratory closet, 56. 
Lactic acid, 49, 76. 
Lancet, The, 57. 
Landau, 298. 
Larrabee, 308. 
Lavage, 66. 

Leube, mixed meal of, 51. 
Leube, test meal of, 46, 77. 
Lilienthal, H., 261, 264, 266. 
Lister, 324. 
Liver, floating, 318. 
Loretta, 152. 
Louyer-Villermay, 323. 
Lund, 147, 151, 158. 
Lymphatic connections of the stom- 
ach, 205. 



Malaria, 55. 

Malpighi, 7. 

Maydl, 201, 223. 

Mayo, W. J., 205, 210, 215, 219, 223, 

244, 252, 268, 269. 
Mayos, 201. 
McBurney, 272. 
McBurney incision, 344. 
McDowell, 324. 
McGraw ligature, 195, 208. 
Megastria, 66. 
Melena, 53. 
Melier, 323. 
Mestivier, 323. 
Metastasis, 205. 
Methods, 35. 
Middle Ages, 22. 

Mikulicz, von, 169, 198, 201, 222. 
Mikulicz's point of election, 214. 
Mintz, 142. 
Mixter tube, 265. 
Monaud, 250. 
Most, 205. 

Motor insufficiency, diagnosis of, 75. 
Moynihan, B. G. A., 121, 147, 152, 

198, 223. 
Munro, J. C, 152, 157, 179, 220. 
Murphy button, 195, 208, 273. 
Murphy, F. T., 147, 151, 158, 346. 
Murphy, J. B., 198, 201. 

Naunyn, 233, 245. 

Nephroptosis, 307. 

Nervous conditions, 56. 

Niemeyer's " Practical Medicine," 58. 

Obstruction, pyloric, 64, 147. 

Obstruction, symptoms of pyloric, 71. 

Ochsner, A. J., 240, 330, 331. 

Operation, effect of, on stomach func- 
tion, 144. 

Operation for distortion of the stom- 
ach, 160. 

Operation for pyloric stenosis, 153. 

Operation of Koux, 193. 

Operation upon the stomach, tech- 
nique of, 168. 

Operations, exploratory, 170. 

Operative treatment of the stomach, 
139. 

Oppler-Boas bacillus, 203. 

Oppolzer, J., 61. 

Osier, William, 333. 



394 



INDEX 



Pagensteclier, 175. 

Pain, 85, 103, 115, 127. 

Palpation, 41, 42. 

Pancreas, 276. 

Pancreas, hemorrhage into the, 277, 

279. 
Pancreatic cyst, 283, 290. 
Pancreatic lithiasis, 282. 
Pancreatic reaction, 286, 287. 
Pancreatitis, acute, 277, 280, 292. 
Pancreatitis, chronic, 294. 
Pancreatitis, chronic interstitial, 277, 

281. 
Pancreatitis, the treatment of, 289. 
Paracelsus, 10, 22. 
Parker, Willard, 324, 325. 
Pawlow, 233. 
Pepper, W., 334. 
Percussion, 42, 43. 

Perforation from duodenal ulcer, 128. 
Persians, 2. 
Physick, P. S., 64. 
Plato, 3. 
Pratt, J. H., 308. 
Ptosis, 64. 

Ptosis, abdominal, 298. 
Ptosis, congenital, 300. 
Ptosis, causes of, 299. 
Ptosis of the stomach, 306. 
Pylorectomy, 207. 
Pyloric stenosis with gastrectasis, 

148. 
Pylorus, spasm of, 64. 

Quadrants, abdominal, 38. 

Rectum, examination by, 39. 
Renal region, 39. 
Results, end, 255. 
Results, immediate, 219. 
Ribbert, 322. 

Richardson, M. H„ 201, 264, 270, 274. 
Richter, 250. 
Riedel, 232. 
Robson, Mayo, 157. 
Rodman, 192. 
Rogers, J. T., 244. 
Rogers, John, Jr., 143. 
Route, retromuscular, 344. 
Roux, 201. 
Rudbeck, O., 12. 

Rules, cardinal, for operations on bile 
ducts, 255. 



Rush, 1, 23, 28. 
Rydygier, 169, 200. 

Sahli's test, 287. 

Saracenus, 323. 

Schlatter, 200. 

Schroder, 245. 

Scudder, C. L., 171, 181. 

Senn, N., 201. 

Sharp, 250. 

Shock, 216. 

Siatorrhoea, 285. 

Sims, Marion, 250, 324. 

Soupault, 142. 

Spallanzani, 17. 

Spivak, C. D., 70. 

Splanchnoptosis, 298. 

Stahl, 14. 

Statistics, 236. 

Steatorrhcea, 285. 

Steinthal, 181. 

Stendel, 142. 

Stenson, N., 8. 

Stern, 254. 

Stockton, C. D., 110. 

Stomach, cancer of, 124. 

Stomach, chemistry of the, 112. 

Stomach, dilatation of the, 65, 72, 

82. 
Stomach, distortion of the, 64, 158, 

160. 
Stomach, hour-glass, 120, 147. 
Stomach, hypertrophy, 79. 
Stomach, non-malignant diseases of 

the, 139. 
Stomach tube, 64. 
Suture, Cushing, 176. 
Sylvius, F., 12. 
Sylvius, J., 12. 

Terrier, 239. 
Test, fermentation, 78. 
Test, guaiac, 52. 
Test, HC1, 47. 
Test meal, 44. 
Tetany, 64. 
Tetany, gastric, 163. 
Tiedeman, 66. 
Toft, 325. 

Topfer's reagent, 47. 
Transactions of the London Patho- 
logical Society, 57. 
Treatment, after, 218. 



INDEX 



395 



Treit, ligament of, 183. 

Trendel, 181. 

Tuberculin, 54. 

Tumors of the bile passages, 273. 

Turck, F. B., 217. 

Ulcer, 64. 

Ulcer, acute gastric, 106. 

Ulcer, chronic gastric, 106, 146, 147. 

Ulcer, duodenal, 126, 233. 

Ulcer, duodenal, perforation from, 128. 

Ulcer, frequency of, 99. 

Ulcer, latent, 101. 

Ulcer, multiplicity of, 111. 

Ulcer, peptic, of the jejunum, 196. 

Ulcer, peptic, medical treatment of, 

130. 
Ulcer, round, 106. 
Ulcer, simple, 105. 
mce*, stomach and duodenal, 99. 
Ulcer, symptomology of, 103. 
Urine from each kidney, 54. 



Valentine, B., 9. 
Vesalius, Andreus, 6. 
Virchow, 109, 298. 
Virchow's Archives, 57. 
Volz, 334. 
Vomit, 128. 

Vomiting, 85, 103, 118. 
Volvulus, 70. 

Wagner, 134. 
Walter, F. A., 250. 
Wegeler, 323. 
Welch, W. H., 99. 
Wharton, T., 8. 
White, J. C, 61. 
Whittaker, 334. 
Willy-Meyer, 328. 
Winslow, F., 262. 
Wirsung, J. G., 8. 
With, 325. 
Witzel, 208. 
Wolfler, 169, 193, 200, 201. 



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Introduction to the Outlines of the Principles of Differential Diagnosis, with Clinical 
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The Nervous System of the Child : Its Growth and Health in Education. By Francis 
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The Cell in Development and Inheritance. By Edmund B. Wilson, Ph.D., Professor 
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ZIEGLER 

A Text-Book of Special Pathological Anatomy. By Ernst Ziegler, Professor of 
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